Electronic connectivity at the mercy of humans

1. Electronic connectivity at the mercy of humans Andrew Dalley D Pub Hlth, MB, BS, Adv Dip Bus Mgt, DRACOG CEO, Illawarra Division of General Practice, Hon Principal Fellow, Faculty of Informatics, UoW

2. Euphoric grandiosity of 2008 “Doctors should have all of the information about all of their patients all the time” Kaiser’s CEO and Chair, George Halvorson, quoted in the Washington Business Journal (Rauber, 2008).

3. Parochial pragmatism of 1998 “I’m a firm believer that the concept of general practice and computerisation is being held back by finance, underdevelopment and political decisions by government.That doesn’t stop me computerising my practice.” The late Harold Shipman at the inquest into the death of Kathleen Grundy 1998

4. I DIANA PRINCESS OF WALES of Kensington Palace London W8 HEREBYREVOKE all former Wills and testamentary dispositions made by me AND DECLARE this to be my last Will which I make this First day Of June One thousand nine hundred and ninety three 1 I APPOINT my mother THE HONOURABLE MRS FRANCES RUTH SHAND KYDD of Callinesh Isle of Seil Oban Scotland and COMMANDER PATRICK DESMOND CHRISTIAN JEREMY JEPHSON of St James's Palace London SW1 to be the Executors and Trustees of this my Will2 I WISH to be buried 3 SHOULD any child of mine be under age at the date of the death of the survivor of myself and my husband I APPOINT my mother and my brother EARL SPENCER to be the guardians of that child and I

5. IM - auditing The truth soon surfaced, when practice receptionist Marjorie Walker stumbled upon some disturbing entries in a druggist’s controlled narcotics ledger. The records showed how Shipman had been prescribing large and frequent amounts of pethidine in the names of several patients. Ted Ottley

6. IM - benchmarking Local undertaker Alan Massey began noticing a strange pattern: not only did Shipman’s patients seem to be dying at an unusually high rate; their dead bodies had a similarity when he called to collect them. “Anybody can die in a chair,” he observed, “But there’s no set pattern, and Dr. Shipman’s always seem to be the same, or very similar. There was never anything in the house that I saw that indicated the person had been ill. It just seems the person, where they were, had died.

7. The PC: the basis of an EHR For 14 out 17 quality indicators, there was no significant difference in outcomes between consultations using an electronic record and those not using one. (Linder et al, 2007).

8. EHR History Summary Fragmented detail Comprehensive Multiple user organisations

9. Why use an EHR? I don’t know, but somebody else may have known, bits of it, or thought they did, at some other time, in some other place, and its worth my while to find out.

10. Is it worth my while to find out? Information mastery Relevance* Validity Work IM = Slawson and Shaughnessy, 1994

11. Relevance

14. PACS

15. Validity

16. Validity Cancer surgery databases • Omission rate • Upper GIT cancers 27.6% • Breast cancer 19.6% • Colorectal cancers 32.7% • Clinical data associated with high omission rate • Demographic data associated with low omission rate Warsi et al 2002 Euro J Surg Oncol 28(8): 850-856

17. Validity Orthopaedic database V clinical records • 62% completeness but • 96% accuracy. • Researchers’ comments: “Compliance by users was poor. Completeness of data capture can be improved by providing feedback to users”. Barrie and Marsh,1992, BMJ 304: 159-162

18. ----- Original Message ----- From: <iahsdocmail@iahs01.iahs.nsw.gov.au> To: <FAKEID@iahs.nsw.gov.au> Sent: Wednesday, February 12, 2003 5:35 PM Subject: anony mous; Cas Admit; FRACTURED PELVIS ******** MESSAGE FOR DR F AKEID ********** > MRN 0X1-4X-XX > Name ANON YMOUS > Address C-MAYFLOWER RETIREMENT VILLAGE, GERRINGONG, 2534 > DoB XX/XX/19XX Age: XX Sex: M > Hospital KIAMA HOSPITAL > AMO DR A COLLINS > Pres. Prob FRACTURED PELVIS > Cas Admit 31/01/2003 11:10 MED > Discharged 11/02/2003 05:57 > Dis Status Died with no autopsy performed > DocMail No. B45499

19. Work

20. Sometimes there are just too many competing interests

21. Where does it work OS?

22. Where does it work? Kaiser Permanente “Customers”: 8.6 million Dollars: 4 billion ($465.11 each) Washington Business Journal, 6.05.2008 Veterans Health Information Systems and Technology Architecture (VistA)

23. Lesson one • Be prepared to spend money up front for (dubious) downstream benefit.

24. Why did it work? Autonomous organisation Service linked to patient entitlement Audit quality service delivery Known protocols of care including medications Automatic patient enrolment

25. Where does it not work?

27. Trouble in Paradise KP in Paradise • “Sad story of the failed implementation” of an ehr • Decision not made with clinicians • Clinicians not involved in design • Clinical productivity declined • Poor leadership (“Culture eats strategy for breakfast”) Teasdale, S., Commentary: Trouble in paradise – learning from Hawaii, BMJ, Vol 331: 03.12.2005

28. KP in Hawaii • “We had a 12 month preparation period. The product wasn’t delivered for another 14 months. That affects your culture” • The delay … “Lots of things happen in people’s lives. And my internist need to go do other things. And my paediatrician also needed to move. So the implementation date is shifting, and my players are (too)”. • “Several respondents doubted whether they would be able to achieve pre-CIS productivity levels”. Scott et al, 2005, Kaiser Permanente’s experience of implementing an electronic medical record, BMJ, Vol 331, p1313 ff

29. Lesson 2 • Clinician engagement at design and implementation phases • Failure to improve clinical productivity results in increased clinician resistance • The ehr should support existing clinical work patterns not require new ones. • Trade-offs are an important element of ehr implementation.

30. Trouble in Paradise • Two major solutions • Clinician champions • Achieve ownership by clinicians Teasdale, S., Commentary: Trouble in paradise – learning from Hawaii, BMJ, Vol 331: 03.12.2005 6 by 4 bygone

31. Where did it not work? Limpopo

32. Limpopo, SA, 1999 IBM 134m Rand project Hospital based Poor implementation, poor change management Culture phaged strategy again Clinician workload increased No improvement in outcomes 6 by 4 bygone

33. Why does it not work? Poor design, implementation Relevance, validity and workload of clinicians Critical mass of information, patients and clinicians Patient enrolment (opt in v opt out) 6 by 4 bygone

34. Are we any better?

35. Health Connect in Oz Inherent pilot approach • ehealthNT • Brisbane (GP Partners) Health Record eXchange • Ballarat and Hobart • SA • Northern Rivers • Maitland/Westmead • Barwon Health (Geelong) • Each state “is progressing with its own independent E-health program without co-ordination or governance at a national level.” (Booz and Co, 2008, p28)

36. Medicolegal risk • Bounds of knowledge risk (ie how far do I have to go to find out about this patient) • How do I know there is information about this patient? • Who should access the information? • Authorship is irrefutable

37. Irrefutability • Police Officer: I’ll just remind you of the date of this lady’s death – 11th May ’98. After 3 o’clock that afternoon, you have endorsed the computer with the date of 1st October ’97 which is 10 months prior, ‘chest pains’. • Dr Shipman: I have no recollection of me putting that on the machine. • Officer: It’s your passcode; it’s your name Ted Ottley http://www.trutv.com/library/crime/serial_killers/notorious/shipman/death_7.html

38. Increased accountability • “Its almost like they didn’t really care what they wrote on paper, but now its electronic and people can read everything” Scott et al, 2005, Kaiser Permanente’s experience of implementing an electronic medical record, BMJ, Vol 331, p1315

39. Barriers • Lack of strategic direction • Poor execution of initiatives • Insufficient clinician engagement (Coiera, MJA, 2007) • Time overruns for sceptical clinicians • Poor acceptance of mooted benefits • Benefits generated by one clinician are utilised by another • Clinician acceptance determined by existing culture of trust and cooperation

40. Barriers • Patient consent (opt in) • High hype to delivery ratio (Booz & Co, 2008) • High rate of burnout from early adopters eg Ballarat • Changes to work patterns • Access to computers • Works best for hospital clerical staff (Laerum, Karlsan, Faxvaag, 2004,Use and attitudes to a hospital information system by medical secretaries, nurses and physicians, BMC Medical informatics and Decision Making; 4:18)

41. Quick wins approach • ADE ($400M - $2B pa, improved patient care) • Prescribing (point to point v centralised v distributed) • Limited functionality EHRs eg Diabetes,CVD • Need assurance changes will improve existing practice • Solution and commercially focused initiatives are the most successful eg PACS reporting, pathology, prescribing, e-booking Booz & Co, 2008, E-health: Enabler for Australia’s health reform, National Health and Hospitals Reform Commission (Authored by Christopher Bartlett and Klaus Boehncke in conjunction with Dr Mukesh Haikerwal)