What we are talking about here, from Cartwright to Leape, is a patient-centered system.
From past and current definitions, we see a clear trend in the description of what patient-centered care involves: sharing information, shared understanding and engagement between provider and patient, continuity of care, a supportive and transparent environment, respect for the patient and their values and preferences, and the role of the family. These are all issues that we see arising in complaints to HDC.
Information technology plays an important role in achieving this vision of a patient centred system. Recent discussion in the literature has focused on the role that information technology can play in achieving patient-engagement goals, and technology can help patients become more involved in their own care, which is especially important in managing chronic conditions. Discussions centre on the belief that patients who have the tools to manage their own health care data, who have ready access to reliable health-related information, and/or who can communicate more effectively with health professionals will be capable of making more informed decisions and will experience better outcomes. Information technology also plays a crucial role in respect of seamless services, and it is this particular issue that becomes evident in the case studies we will discuss later.
The Plan sets priorities for regional and national IT investments over a five-year period. The plan notes that a barrier to patient-centered care in New Zealand is the fact that every day clinicians are managing patient care while working around the fact that information is held in separate locations, creating barriers to a better, sooner and more convenient health experience.
The following graphs illustrate that the New Zealand primary care sector are international leaders in the implementation and use of health IT. Analysis of the 2006 Commonwealth Fund data by Davis et al (2009) found that: There is a strong relationship between IT capacity and patient safety: the greater the capacity, the more likely a practice has a patient safety system in place. More than 43% of physicians with high IT capacity had a process for dealing with adverse events, compared with 27% of practices with low IT capacity; and31% of primary care physicians with high IT capacity and 28% of those with medium IT capacity reported their ability to provide quality medical care had improved over the past five years. By contrast, just 22% of those with low IT capacity reported similar views(Davis, K., Doty, M., Shea, K., and Stremikis, K., “Health Information Technology and Physician Perceptions of Health Care Systems and Quality of Care” Health Policy (November, 25, 2008))
That IT must play a central role in the redesign of the health care system is a central theme in the report, in particular, in reference to the following matters: the importance of a strong information infrastructure in supporting efforts to reengineer care processes, manage the burgeoning clinical knowledge base, coordinate patient care across clinicians and settings and over time, support multidisciplinary team functioning, and facilitate performance and outcome measurements for improvement and accountability; the importance of building such an infrastructure to support evidence-based practice, including the provision of more organized and reliable information sources on the Internet for both consumers and clinicians, and the development and application of clinical decision support tools;the need to build information-rich environments for undergraduate and graduate health education, as well as the potential to enhance continuing education through Internet-based programs.
Information technology is only one of many important steps to advance patient-centred care. Installing health IT in a health care organisation will not, in itself, result in improved care. “Health IT should not be viewed as an end in itself. Rather, it should be used to reinforce healing relationships, continuity, and shared mind. Patient-oriented information systems should give the clinician easy access to information about the patient’s family and other contextual data; provide space to document the patient’s treatment preferences; and not distract the clinician with burdensome documentation for administrative and billing purposes. Health IT should help patients be more active in clinical encounters by helping them formulate questions.”Safety, efficiency and quality need to be based on relationships, as well as on processes and products.
As is noted in the report, the evidence in the literature about the impact of IT on patient safety is mixed, but shows that the challenges facing safer health care and safer use of health IT involve the people and clinical implementation as much as the technology itself. Many problems with health IT relate to usability, implementation, and how software fits with the clinical workflow, not just problems with coding errors or human errors in using the software as is often presumed.
These recurring themes in complaints to HDC show a clear correlation between the concepts that define patient-centered care and complaints to HDC. They also serve to highlight areas of concern in the interactions between health IT and the “larger sociotechnical system” that can impact on patient safety.
The results of the CT scan were sent to Dr C, and the report noted that cholecystectomy clips were seen, and the impression was “post-cholecystectomy status with mild prominence to the common hepatic duct and left hepatic duct”. Dr C stated that the CT result “came up unexpectedly on the new iSOFT Clinical Results computer program”. Dr C stated that when he opened the report he noted Mrs A’s name at the top, but he did not recognise it as Mrs A’s particular case. He said he attempted to print the report but lost it when he unintentionally sent the report to a remote printer and could not find it again on the computer. He expected to receive a printed copy of the report as well so that he could check it later with the appropriate patient’s file, but he did not. Dr C accepted that the CT report was crucial, but stated that it “was lost with a new information systems process”. The DHB advised that a new computer programme was introduced in early 2009. The DHB stated that it is it’s practice to ensure that any new technology, particularly where it impacts on patient care, is fully supported by staff training. Training for the new Clinical Workstation application (the application that enables the DHB to store electronic results and letters form the laboratory and radiology) began in April 2009 with a powerpoint presentation to senior staff and management, and a discussion on process change requirements. Training dates were arranged, and on 30 April consultants and ED staff were provided with individual training on the application. Dr C was provided with an individual 20-minute training session in his office. He presented as computer literate and confident in the Clinical Workstation application. At the time of these events, the DHB was still using the paper-based system whereby paper results were delivered to the doctors and placed on the paper file. There was a dual system, paper and electronic, for about three months until the DHB was satisfied that the electronic system was functioning as expected.
What is interesting about this, is that in the IOM (2012) report, it is noted that the timeframe for greatest threats to safety from health IT is during the initial implementation, when workflow is new, a steep learning curve threatens previous practice, and non-performance of any aspect of a technology causes the user to seek immediate alternative pathways to achieve a particular functionality. As also noted in the IOM (2012) report: “when health IT is designed and implemented in a manner that complements how information is transferred between health professionals and patients, the reliability of patient information – and therefore patient safety – can increase … However, when health IT unexpectedly alters workflow, it has the potential to hinder clinicians’ abilities to communicate patient information … and it may result in increased cognitive workload, clinicians ignoring computer-generated information, continued reliance on various traditional modes of communication, creating of unsafe workarounds, and more time spent dealing with health IT than with patient care.”
Mrs A’s clinical records were contained in two separate files. One contained her medical records from 1981 to 1996, which included her previous gallbladder removal in January 1996. The second contained Mrs A’s clinical records from 1999 to 2009. Dr C said that because Mrs A “did not admit” to previous investigations or surgery for similar symptoms, the earlier notes were not called for. Mrs A said that when Dr C talked to her about having her gallbladder out she thought she had had that done; however she was unsure whether the operation she previously had for “stones” was for kidney or gall bladder stones. She thought that her medical notes would record her operations and that Dr C would remember them.
The serious consequences Mrs A sustained arose as a combination of individual error on the part of Dr C, and systems issues on behalf of the DHB.Dr C failed to obtain full and accurate information about Mrs A’s previous medical history, and then at surgery misread the anatomy. The onus is on the clinician to ask the relevant questions, examine the patient and keep proper records … it is inappropriate to claim that these events were the result of a mislaid scan report, missing clinical files and a failure of the patient to provide information. I acknowledge that it takes time for new systems to be bedded down, and for all users of the system to become proficient in its operation. In this case, the right person, Dr C, received the critical information in the CT scan in a timely manner, but because of his unfamiliarity with the system this important information was misplaced. Dr C was found in breach of Rights 4(1) and 4(4) for not providing services with reasonable care and skill and failing to minimise harm; Right 6(2) by failing to provide the information that was necessary for Mrs A to make an informed choice about surgery; and Right 7(1) for failing to obtain informed consent. The DHB did not provide a complete set of Mrs A’s clinical records to Dr C. I appreciate that in some cases, where a patient has had multiple admissions over a long period, the volume of notes would be considerable. However, it is important that significant details of a patient’s clinical history, such as previous surgeries and allergies, are readily available to current clinicians – a summary of salient information should be accessible to the clinician. We need to have systems in place that protect from human error. In my opinion, the DHB had a duty to have a system in place to ensure that the responsible clinician was alerted to the existence of relevant information. The DHB was found in breach of Right 4(1) for failing to have adequate systems in place to ensure information was provided, which adversely affected the care provided to Mrs A.
It is evident that a combination of factors contributed to this very serious incident. I accepted that Dr C’s unfamiliarity with the newly introduced clinical record computer system caused him to send the critical CT scan report to the wrong printer. However, he failed to follow the report up even though he had read and acknowledged it. He noted that Mrs A was the patient and that cholecystectomy clips were visible – evidence that a cholecystectomy had been performed – but did not connect this to Mrs A when he saw her 10 days later. He overlooked other important cues, the equivocal liver function test results, the ultrasound scan and the previous operation notes, which should have alerted him to the possibility that his diagnosis and management plan should be reviewed.
Communication of information to the right person at the right time is critical to safe care. I accept that it may be impractical where voluminous amounts of material exist, to deliver all notes to clinicians. Nonetheless, it is axiomatic that relevant history should be considered when treating patients. The system needs to reliably alert treating clinicians to the existence of relevant information, particularly in relation to that patient’s history in that institution.
My office is currently investigating another case where a practitioner, instead of using his mouse to file electronic results, used the program’s short-cut keys. Unfortunately, in the case under investigation, the general practitioner used the wrong short-cut key, and the results were inadvertently filed. The practitioner noted his concern that a contributor to this error was that the program’s short-cut keys for filing results are too close together. There was no “pop-up” or “warning” to check whether he intended to file the results. This error had significant effects for the consumer involved.
My Office frequently receives complaints about mishandled referrals. The case just discussed is similar to one currently under investigation by my Office, where a referral was faxed with a test result attached. The test result, which provided pivotal information about the man’s condition and priority status, was illegible. Staff did not track down a legible copy of the test results, the referring general practitioner did not speak with the surgeon to which he was referring the patient, the referral was not acknowledged – no information was provided that the referral had been received and was being actioned. The man was given a lower priority and died awaiting treatment.
I want to see providers overcome the problem of passivity in response to referrals.
While Health IT creates opportunities to improve patient safety that do not exist in paper-based systems, implementation of health IT does not, in itself, automatically improve patient safety. Health IT can be a contributing factor to adverse events. As noted in the IOM report, the way in which health IT is designed, implemented, and used can determine whether it is an effective tool for improving patient safety, or a hindrance that threatens patient safety and causes patient harm.
Health Informatics and Patient Safety
Health Informatics and Patient Safety Anthony Hill Health and Disability Commissioner HINZ Conference 24 November 2011
Cartwright Vision“*I+ advocate a system which will encouragebetter communication between patient anddoctor, allow for structured negotiation andmediation, and raise awareness of patients’medical, cultural and family needs. The focus ofattention must shift from the doctor to thepatient.”Judge Cartwright, 1988, page 176
Cartwright Recommendations1. Administrators and health professionals need to listen to their patients, communicate with them, protect them, offer them the best health care within their resources, and bravely confront colleagues if standards slip.2. “Hospital Board (or Area Health Board) representatives should take greater responsibility for the patients’ welfare. They should ensure that the duty to safeguard the patients’ health is the administration’s paramount consideration at all times. Judge Cartwright, 1988, page 172 6
Bristol 2001“Placing the safety of patients at the centre of the hospital’sagenda is the crucial first step towards creating and fostering aculture of safety. This means that safety must be everyone’sconcern, not just that of the consultant, or the nurse in charge.…The safety of patients, the safety of their clinical care, is amatter for everyone, from the trust boardroom to the wardassistants. Safety requires leadership from the highest level ofmanagement. It requires constant vigilance. It should beconsidered in everything that the organization does. It is not ashort term project but a commitment for 365 days a year. Aculture of safety can only really be created when a concern forpatients’ safety is embedded at every level of the organization.”This quote is from: The Report of the Public Inquiry into children’s heart surgery at theBristol Royal Infirmary 1984–1995 (Available at: http://www.bristol-inquiry.org.uk) 7
20 Years On: A Vision for Healthcare“We envisage a culture centredon teamwork, grounded inmission and purpose, in whichorganisational managers andboards hold themselvesaccountable for safety andlearning to improve.” Leape et al 2009 8
Recent Definitions“A patient-centered approach fosters interactions in whichclinicians and patients engage in two-way sharing ofinformation; explore patients’ values and preferences, helppatients and their families make clinical decisions; facilitateaccess to appropriate care …”“Patient-centered interactions strive to achieve a state ofshared information, shared deliberation, and shared mind.” Epstein et al (2010) 9
A Patient Centred System Engagement Patient Seamless Transparency Centred Service System Culture 10
The NZ ContextMinisterial Review Group Report 2009“Health professionals across the differentinstitutional settings would find it much easier toprovide seamless care if they shared easy access toa common patient record … To be successful, atransferable electronic patient record needs tobecome part of the routine way health professionalswork and work together. There is real advantage instarting to develop the ability of community,primary and secondary clinicians to work togetherfirst, rather than relying on an IT project to ‘push’these changes.”
The NZ Context National Health IT Plan September 2010“To achieve high-quality health care and improvepatient safety, by 2014 New Zealanders will have acore set of personal health information availableelectronically to them and their treatmentproviders regardless of the setting as they accesshealth services.”
Doctors Use Electronic Patient Medical Records in Their Practice, 2006 and 2009* Percent 2006 2009 98 99 97 96 95100 92 89 79 72 75 50 46 42 37 28 23 25 0 NET NZ UK AUS GER US CAN* 2006: “Do you currently use electronic patient medical records in your practice?”* 2009: “Do you use electronic patient medical records in your practice (not including billing systems)?” 14Source: 2006 and 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Crossing the Quality Chasm (2001)• Health care should be supported by systems that are carefully and consciously designed to produce care that is safe, effective, patient- centred, timely, efficient, and equitable• IT has a critical role in the design of those systems: “IT must play a central role in the redesign of the health care system if a substantial improvement in health care quality is to be achieved”
Patient safety requires more than good IT systems“Although the use of health information technology andsimilar infrastructure supports are important enablers ofpatient-centred care, the concept, at itscore, encapsulates healing relationships grounded instrong communication and trust.”“Investments in infrastructure … and informationtechnology (IT) applications … are important in fosteringenvironments that enable accessible, coordinated, andresponsive care. Yet … the presence of infrastructure andIT alone are not sufficient to produce healingrelationships and effective communication.” Epstein, et al. (2010)
11 Years On: Health IT and Patient Safety“It is widely believed that health IT, when designed,implemented, and used appropriately, can be apositive enabler to transform the way care isdelivered. Designed and applied inappropriately,health IT can add an additional layer of complexityto the already complex delivery of health care,which can lead to unintended adverseconsequences, for example, dosing errors, failing todetect fatal illnesses, and delaying treatment due topoor human-computer interactions or loss of data” IOM (2011) Health IT and Patient Safety: Building Safer Systems for Better Care
11 Years On: Health IT and Patient Safety• “To improve safety, health IT needs to optimize the interaction between people, technology, and the rest of the sociotechnical system.”• “Adhering to well-developed practices for design, training, and use can minimize safety risks. Building safer health IT involves exploring both real and potential hazards so that hazards are minimized or eliminated.” IOM (2011)
Recurring themes• Learning system• Getting the basics right• Read the notes• Ask the questions• Talk to the patient• Listen to the patient and the patient’s family• Ensure continuity of care• Take responsibility
Case Example: 09HDC01505In June 2009 Dr Coperated on Mrs A toremove her gallbladder unaware thathe had alreadyremoved her gallbladder 13 years before
Case Example cont …Preoperative assessment:• Pre-operative CT imaging indicated the patient did not have a gall bladder• Scan sent electronically to surgeon• Dr C did not mentally connect the report to Mrs A• Dr C mislaid the report when he forwarded it for printing• A paper copy was not attached to Mrs A’s file• Mrs A asked Dr C about the results of the scan on the morning of her surgery – Dr C discussed an earlier ultrasound and not the CT report
Case Example cont …“Unfamiliarity with the new electronicinformation systems might have explained Dr Coverlooking his receipt of the critical CT scanreport, if it were not for the fact that Mrs Aasked him about the result of a scan on themorning of her surgery. This was a missedopportunity for Dr C to review his preoperativework-up of this patient.”
Case Example cont …Review of medical records• Mrs A’s clinical history was contained in two separate files• Mrs A’s most recent clinical notes were available for review• Mrs A’s old medical records were not received and reviewed
Case Example cont …Outcome• During surgery, Dr C initially believed he had removed a shrunken gallbladder• Later realised a major duct injury had occurred• Mrs A required corrective surgery
Case Example cont …Why did this happen?Where the two roads meet: individual responsibilityand organisational responsibility.
Case Example cont …In any healthcare system,there are a series of layers ofprotections and people,which together operate todeliver seamless service to apatient. When any one ormore of these layers do notoperate optimally, thepotential for that level toprovide protection, ordeliver services, iscompromised.
Case Example: take home messagesThe right information to the right person at theright time• Records must be accessible• Records must be integrated• Records must be of a high quality and contain all relevant information
Case Example: take home messagesSystem “warnings” and “pop-ups” are crucial• What difference might this have made in the gallbladder case?• What warnings are there if the wrong short-cut key is used to file results?
Case Example: Take home messages• In the dry language of systems and processes, of transmission technologies and referral protocols, we can miss the very human dynamics that give life to these systems and processes.• Whatever referral system is operating between providers, it has to work for patients, who should have justified confidence that referrals will lead to action in sufficient time to treat preventable problems
Referral issues• Referrals must be communicated clearly• Referrals must be acknowledged• Referrals must be acted on
A vision for healthcare: transforming conceptsThe vision is a patient-centered system• Transparency – free (respectful) sharing of information at all levels• Integrated care platform – organisational structure and system that enhances quality and patient safety• Consumer engagement – “nothing about me without me” Leape et al 2009
Role of health IT• IT is a crucial enabler in improving the quality and safety of health service delivery, and in the move towards a patient centred system• However, “Health IT may cause harm if it is poorly designed, implemented, or applied. Poorly designed, implemented, or applied, health IT can create new hazards in the already complex delivery of health care.” (IOM, 2011)• Technology does not exist in isolation from its operator – the design and use of health IT are interdependent
Summary: take home messages• Seamless service not passive systems• Records must be accessible• Records must be integrated• Records must be of a high quality and contain all relevant information• System “warnings” and “pop-ups” are crucial• Referrals must be communicated clearly• Referrals must be acknowledged• Referrals must be acted on• Records must be patient accessible: careful consideration should be given to privacy and security issues
Conclusion“A constant, ongoing commitment to safety –from acquisition to implementation andmaintenance – is needed to achieve safer, moreeffective care.” IOM (2011)