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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

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. Current State of Healthcare. Care is complex Care is uncoordinated

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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

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  1. Improving Patient Safety with Information and Communication TechnologyWanfang’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

  2. Current 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 IOM, Crossing the Quality Chasm

  3. Sentinel Events Caused death or permanent loss of function, reportable Adverse Event (Iatrogenic Injury) Medical Errors Negligence Sub-standard care, legal criteria Near Misses No harm done Preventable Adverse Events Preventable by training, protocol, systematic monitoring and Information Technology (20~30%)

  4. The Swiss Cheese Model of System Accidents J.Reason, BMJ 2000;320:768-770

  5. Preventable?By IT?

  6. 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 Bates and Gawande, NEJM 2003

  7. IT infrastructure for Patient Safety • Electronic Medical Record (EMR) • Computerized Physician Order Entry (CPOE) • Clinical Decision Support System (CDSS) and Reminder System

  8. Evidence After implementation of Clinical Decision Support System (CDSS)

  9. What data do we have?

  10. Data Interaction Model for AE detection Age, sex, allergy, weight, height, blood type, body temperature, …etc. e.g. Penicillin vs PCN allergy Patient Profile Current and/or chronic dz, DM, H/T, Pregnancy…etc. CBC, D/C, Chem-20, hCG, PT, APTT, INR…etc. 12 5 Laboratory Data Diagnosis& History 11 3 4 e.g. Retinoids vs pregnancy e.g. Coumadin vs INR 10 2 9 8 Surgery, transfusion, endoscopy, angiogram, PTCA, rehabilitation…etc. Medication Procedures 1 7 Propanolol vs theophylline, Cipro vs aminophylline, Acetaminophen vs Phenytoin…etc. e.g. Wafarin vs angiogram YC Li et. al., 2004

  11. All 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)

  12. Where to Start?

  13. JCAHO 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

  14. Current Systems in WFH

  15. 推動病人安全之行政架構

  16. 病安執行小組 病安資訊中心 Patient Safety Informatics Transform 3-year Retro -spective Database Trial Run Online 醫囑系統 Reminders Collect 由各臨床科填寫 PSI Center operations

  17. 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

  18. Lab 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 !!!

  19. 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

  20. 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

  21. PHS short msg. Radiology Report e-mail Physicians complete info. Nurses HRRKnowledge Base and Engine Lab Results Patient Safety Departmentdirectors Pathology Report HRR Monitor Departmentsecretary High Risk Reminder and Surveillance

  22. 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

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

  24. PHS HRR sample

  25. E-mail HRR sample

  26. 高風險自動警示系統E-mail畫面-Lab檢驗

  27. 高風險自動警示系統E-mail畫面 RAD檢驗

  28. 高風險自動警示系統E-mail畫面 PATH檢驗

  29. 高風險自動警示系統畫面

  30. Lab HRR 通報類別月分析

  31. Lab HRR Ratio

  32. Path HRR Monthly Report

  33. RAD HRR Monthly Report

  34. Evaluation of the HRR System (Source: DeLone & McLean, 1992)

  35. The D & M model and hypotheses H1 System S ystem U se Q uality Organization Impact H4 Individual H5 H3 Impact Info. H2 Quality User Satisfaction

  36. The D & M model and hypotheses • 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.

  37. Respondents • 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

  38. Answers to the Questionnaire

  39. Hypotheses Beta 結果 Information quality 0. 704*** significant H1 à System u se System quality 0.049 Information quality 0.813*** significant H2 User satisfaction à System quality 0.054 H3 System u se User satisfaction 0.886*** significant à User satisfaction 0.711** signific ant H4 Individual impact à System u se - 0.96 H5 Individual impact Organizational impact 0.617*** significant à *p < 0.05; ** p < 0.01; *** p < 0.001 Hypothesis Testing

  40. Results • 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)

  41. Discussion • HRR is well-received among most physicians • HRR can improve patient safety and quality of care • Information quality is more important than system quality

  42. Conclusion

  43. Questions and Comments http://gimi.tmu.edu.tw/ http://li.tmu.edu.tw

  44. Questions and Comments

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