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Health Informatics and Patient Safety

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Anthony Hill
Health and Disability Commissioner
(Thursday, 11.00, Keynote)

Published in: Health & Medicine
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Health Informatics and Patient Safety

  1. 1. Health Informatics and Patient Safety Anthony Hill Health and Disability Commissioner HINZ Conference 24 November 2011
  2. 2. Flourishing the partnership
  3. 3. Overview1) Vision2) Health IT in NZ3) Health IT and patient safety4) Themes, case examples5) Summary: take home messages
  4. 4. VISION
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. A Patient Centred System Engagement Patient Seamless Transparency Centred Service System Culture 10
  11. 11. HEALTH IT INNEW ZEALAND
  12. 12. 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.”
  13. 13. 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.”
  14. 14. 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.
  15. 15. HEALTH IT ANDPATIENT SAFETY
  16. 16. 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”
  17. 17. 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)
  18. 18. 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
  19. 19. 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)
  20. 20. THEMES AND CASE EXAMPLES
  21. 21. 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
  22. 22. Case Example: 09HDC01505In June 2009 Dr Coperated on Mrs A toremove her gallbladder unaware thathe had alreadyremoved her gallbladder 13 years before
  23. 23. 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
  24. 24. 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.”
  25. 25. 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
  26. 26. 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
  27. 27. Case Example cont …Why did this happen?Where the two roads meet: individual responsibilityand organisational responsibility.
  28. 28. 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.
  29. 29. 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
  30. 30. 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?
  31. 31. 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
  32. 32. Referral issues• Referrals must be communicated clearly• Referrals must be acknowledged• Referrals must be acted on
  33. 33. Summary: take home messages
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. Conclusion“A constant, ongoing commitment to safety –from acquisition to implementation andmaintenance – is needed to achieve safer, moreeffective care.” IOM (2011)
  38. 38. www.hdc.org.nz

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