Patient Safety CME Curriculum Patient Safety: The Other Side of the Quality Equation

1. Patient Safety CME CurriculumPatient Safety: The Other Side of the Quality Equation Under a Grant from The Agency for Healthcare Research and Quality Principal Investigator Christel Mottur-Pilson, PhD Director, Scientific Policy ACP-ASIM

2. Patient Safety: The Other Side of the Quality EquationSeven Modules in Ambulatory Care • Systems • The influence of systems on the practice of medicine. • Cognitive Capacity • Coping mechanisms under information overload and time pressures • Communication • Communication barriers, lack, and unclear communication • Medication Errors • Uniform dosing, look- and sound-alikes, forcing functions

3. Patient Safety: The Other Side of the Quality EquationSeven Modules in Ambulatory Care • The Role of Patients • Patients as allies in patient safety • The Role of Electronic Resources • Supportive products and processes • Idealized Office Design • Medical practice design to support patient safety

4. Logistics • CME: To receive your CME, please fill out the usual forms • Evaluation form • CME form • Research Grant Surveys • Pre-CME assessment of knowledge level • Post-CME assessment of knowledge level • Six-month follow up to CME • Virtual Patient Safety Electronic Community

5. The Role of Electronic Resources and Patient SafetyHow information technology improves health care delivery outcomes Under a Grant from The Agency for Healthcare Research and Quality Developed by Patricia L. Hale, Ph.D., M.D. Medical Informatics Subcommittee ACP-ASIM

6. Objectives By the end of this module the learner will be able to: • Describe how electronic resources can improve systems and thus influence medical care • Identify the key electronic resources available for use in a practice • Identify a key electronic resource that would be helpful to their practice and why

8. Challenges in Patient Safety are based on System Problems Example: Error = Wrong medication given System problems include: • Cognitive capacity – required information not accessed • Communication – errors in written or oral orders • Medication error – look-alike or sound alike medication given • Patient – not involved in care plan

9. Role of Electronic Resources • Meet the Medical Information Challenge • Expanding complexity of knowledge • Increase reliability of system • Supportive products • Supportive processes

10. Information Technology to Improve Patient Safety • Electronic medical records (EMR) • Electronic orders and prescribing: Computerized Physician Order Entry (CPOE) • Electronic decision-support tools • Handheld devices (PDAs) • The electronic office • Pros and Cons • Choosing the most appropriate systems for your office: an algorithm

11. What is an Electronic Medical Record (EMR)? • Electronic version of the traditional patient chart • Can be linked with other patient information and knowledge resources • Can be simple or complex

12. How EMRs Improve Patient Safety • Universal chart access • Electronic interface with clinical information, insurers and other providers • Better availability of data • Quality Assurance • Integration with other types of technology

13. How EMRs Improve Patient Safety • Universal chart access • Electronic interface with clinical information, insurers and other providers • Better availability of data • Quality Assurance • Integration with other types of technology

14. EMR Access and Patient SafetyCase Example: • While “on call” a physician receives a call from a patient followed by one of their partners. The patient is taking warfarin and had a protime done earlier that day and was supposed to call to find out what dose to take but couldn’t get through to the office.

15. What is Computerized Physician Order Entry (CPOE)? • Ordering of tests, medications, and treatments for patient care using computers • Involves electronic communication of the orders • Uses rules-based methods for checking against drug references and other electronic information resources

16. Electronic Prescribing: Improving the Medication Prescribing Process • Avoids • Illegible Prescriptions • Improper Terminology • Ambiguous Orders • Incomplete Information

17. Evidence that CPOE Systems increase safety • Reduction in medication errors • Bates et al. (1998) - 55 percent reduction in serious medication errors. • Improvements in care • Evans et al. - major improvements in rates of antibiotic-associated adverse drug events

18. Medication Orders AutomationCase Example: • Metformin is prescribed to a patient with an elevated creatinine level. • A drug-lab interaction alert warns that use of this medication could result in an increased risk of fatal lactic acidosis.

19. Computerized Physician Order Entry (CPOE)Case Examples: • A physician prescribes warfarin for a patient with chronic atrial fibrillation. • System advises the physician to counsel the patient about vitamin K rich foods likely to interfere with the efficacy of the drug. • The system prints out a patient information sheet that the clinician can review with the patient at the visit. • The drug information database enters smart defaults into the appropriate data fields of the prescription, saving time and ensuring accuracy.

20. CPOE Advantages • Reduces Order Errors • Data regarding current practices • Data collected on variances in practice • Errors eliminated before order is completed

21. CPOE Disadvantages • Errors still possible • Alerts • Multiple steps • Access

22. Decision Support Systems Impact on Patient Safety: • Standardize clinical decision making • Reduce the clinical decision error rate. • Potential to provide patient-specific protocols

23. Electronic Decision Support Systems • Information systems that provide the evidence-based medical knowledge at the time of care

24. Electronic Decision Support Systems • Information systems that provide the best evidence-based medical knowledge at the time of care

27. Computerized Alert Systems can increase patient safety: • Computer-generated messages and e-mail • Real-time alert messages via alphanumeric pagers or cell phones • Integrate laboratory, medication, and physiologic data alerts into a comprehensive real-time wireless alerting system

28. Evidence that Computerized Alerts Improve Patient Safety • Alerts resulted in: • Decrease in time to therapy • Shorter time to resolution of abnormality • Medication being adjusted or discontinued earlier

29. Electronic Decision Support Systems • Other types of Decision Support Systems are: • Algorithms • Guidelines • Order sets/standing orders • Trend monitors • Co-sign enforcers

30. Potential Problems with Electronic Decision Support Systems • Does not eliminate all potential medication errors • Human error still possible • Lack of an interface with other information systems and screening capabilities limits its effectiveness

31. Barriers to the Use of Electronic Decision Support Systems • Administrative vs. clinical systems • Current financial crisis in health care • Interface and infrastructure issues • Choosing the appropriate rules or guidelines • Developing consensus among physician groups • Regulatory and legal issues

32. Decision Support Case Examples: • A patient has been placed on long term antibiotics for a diabetic foot infection by an Infectious Disease consultant. Three weeks later the patient is seen by his or her primary care physicians for protracted diarrhea and Lomotil is ordered.

33. Handheld devices/Personal Digital Assistants(PDAs): what they can do for the physician • Improve access to information at the point of care • Medication databases (PDR, etc) • Drug interaction checking • Calculators and other tools • Knowledge Resources • Patient specific information

34. Handheld devices (PDAs): what they can do for the physician • Allow electronic entering of patient information • Electronic prescriptions • Patient orders • Wireless communications with staff

36. Advantages Improved patient safety Increased efficiency Better communication Improved accuracy of information Disadvantages Cost Time Integration issues Advantages and Disadvantages of an Electronic Office

37. Choosing information technology for your office setting • Where to start • Practice size • Integration with existing technology • What types of electronic resources improve the process

38. Decision Algorithm

39. Decision Algorithm

40. Summary • Medical errors are due to SYSTEM problems. • Electronic Resources can be useful in decreasing medical errors… but only if they are implemented and used correctly.

41. Further References • Bates DW. Using information technology to reduce rates of medication errors in hospitals. BMJ. 2000;320:788–91. • Bates, David W., MD, MSc, Michael Cohen, MS, RPh, Lucian L. Leape, MD, J. Marc Overhage, MD, PhD, M. Michael Shabot, MD and Thomas Sheridan, ScD JAMIA White Paper: Reducing the Frequency of Errors in Medicine Using Information Technology • Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15):1311–6. • Evans, RS, Pestotnik, SL, Classen, DC, Clemmer, TP, Weaver, LK, Orme, JF Jr., Burke, JP, Computer assisted management program for antibiotics and other antiinfective agents. New Engl J Med.. 1998 Jan 22:338(4):232. • Glaser J, Teich JM, Kuperman G. Impact of information events on medical care. Proceedings of the 1996 HIMSS Annual Conference. Chicago, Ill.: Healthcare Information and Management Systems Society, 1996:1–9. • KupermanGJ, Teich JM, Tanasjlevic, MJ, Ma’Luf, N., Rittenberg, E., Jha, A., Fiskio, J., Winkelman, J., Bates, DW. Improving response to critical laboratory results with automation: results of a randomized controlled trial. J AmMedInform Assoc. 1999 Nov-Dec; 6(6): 512-22. • Miller R, Gardner RM. Summary recommendations for responsible monitoring and regulation of clinical software systems. Ann Intern Med. 1997;127:842–5. • Rind, DM., Safran, C., Phillips, RS., Wang, Q., Calkins, DR., Delbanco, TL., Bleich, HL, Slack, WV. Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch Intern Med. 1994 Jul 11;154(13):1511-7. • Overhage JM, Tierney WM, Zhou X, McDonald CJ. A randomized trial of "corollary orders" to prevent errors of omission. J Am Med Inform Assoc. 1997;4:364–75.

42. Patient Safety Interactive Learning Community (PSILC) • Program Information & Updates • All Seven Modules • Refresher Exercises • Email Discussion Groups http://www.acponline.org/ptsafety

43. Refresher Exercises http://www.acponline.org/ptsafety