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Patient Safety and Quality of Care

Patient Safety and Quality of Care

Benefits and implementations

The focus of this issue of eMessenger is Patient Safety and Quality of Care from the ICT perspective. Our first contributor is Dr. Veli Stroetmann from empirica Communication & Technology Research, Germany, who explains how ICT can benefit patient safety and describes some successful implementations and emerging technologies.

Complex care processes, missing information, regular interruptions of ongoing activities, and sometimes chaotic communications all contribute to medical errors and adverse events, and can have a corresponding significant impact on patient safety and the quality of healthcare. eHealth or ICT-based solutions are becoming key tools to cope with these challenges.

“They can guide care processes and support work flows, provide pertinent patient information when and where needed, and improve diagnosis and treatment through decision support,” explains Dr. Stroetmann.

That’s not all. Through the provision of timely health and lifestyle information, eHealth contributes to prevention. Through support for research it contributes to better medical knowledge and guidelines. And eHealth will have a significant impact on better training, improved preparation for surgery or managing long-term conditions. All of these improve patient safety in a wider sense, and lead to improved quality of care.

Successful implementations of eHealth

Embedded in the “right” organisational environment and used by adequately trained clinical staff, CPOE (Computer-based Practitioner/Provider/Physician Order Entry) systems have proven to lead to very significant improvements in patient safety.

“Coupled with medication records and Decision Support Systems they result in faster ordering of drugs or services required, fewer adverse events resulting from allergies or contraindications, avoidance of wrong doses, and fewer mistakes due to communication errors,” says Dr. Stroetmann.

An example of a comprehensive Electronic Patient Record System is Elios, developed at the Institut Curie in Paris. Elios can be accessed by all physicians involved in a patient’s treatment. It is particularly effective when combined with Prométhée – a biomedical informatics search meta-engine used for answering medical questions across many research and clinical databases. Together, Elios and Prométhée have fundamentally transformed healthcare processes and improved patient safety through:

• faster, shared access to comprehensive, accurate, timely clinical data
• real-time clinical audit studies to measure outcomes and control safety/quality
• faster compliance with new clinical guidelines and organisational protocols.

Emerging applications

RFID applications are becoming increasingly common in healthcare environments. An example is the management of blood conserves. RFID enables their fail-safe matching to the corresponding patient. A pilot project is currently ongoing at the university hospital in Saarbrücken, Germany, where some patients are wearing an RFID wrist band that is used to identify them and match with their blood conserves.
Innovative solutions for real-time, contextual decision support hold great promise if tailored to specific clinical needs, integrated in care workflows, adapted to the specific workplace, and designed to minimise disruption of normal processes.

The increased precision, quality and availability of biomedical images can change the way of delivery of healthcare, with an impact on patient safety and healthcare related risks, e.g., through optimising the therapeutic approach; and guiding minimal invasive interventions. Various subspecialties in surgery are bringing image-guided interventions into clinical practice which will make surgery safer.

Modelling and simulation of concrete disease processes can help to predict the results and side-effects of a particular intervention in advance or enable medicines to be evaluated in ‘virtual clinical trials’ without putting people at risk.

“Simulation is also being used as a training and feedback method in which learners practice tasks and processes in lifelike circumstances using models or virtual reality (VR),” adds Dr. Stroetmann, “with feedback from observers, peers and patients, and video cameras to assist improvement in skills. VR simulations are already revolutionising surgical training.”

Dr. Veli Stroetmann obtained an MD from the Academy for Medical Sciences, Sofia, Bulgaria. She worked as a family doctor before continuing her studies and receiving a PhD in Medical Informatics. After four years as a doctor and researcher in Medical and Health Information Science in Sofia, she moved to Germany and joined empirica in 1992 as a Senior Research Fellow. For more than 15 years, her research has concentrated on the application of ICT in the health and long-term care sectors. Together with Dr. Jean-Pierre Thierry, Symbion, she conducted the eHealth for Safety study for the European Commission on the impact of ICT on patient safety and risk management in healthcare. In 2002 she and her husband, Dr. Karl Stroetmann, received an award for “Telemedicine - Human Applications of IT in Medicine" from the Integrata Foundation.

Challenges and guidelines

Our second contributor on this topic is Dr. Jean-Pierre Thierry from Symbion, France, who looks at how EHR can solve specific safety issues, describes some challenges to be faced, and ends up with some practical guidelines.

When Electronic Health Records – whether they are an assembly of records about specific interventions, or an already well-structured and comprehensive database of a wide variety of information about the patient – are implemented and accessible across the organisation, all the clinicians on the healthcare team get a better picture of what’s going on with a patient. They also get all this information in real-time in a more continuously updated way than they did with the paper records.

“This indicates that EHRs can fundamentally contribute to the major patient safety issue of having the right information at the right time, and of supporting streamlined communications among all concerned,” says Thierry.

Ideally, an Electronic Health Record allows clinicians to have a full overview of a patient’s history, diagnoses, allergies and medications, therapies suggested, recent interventions, etc. This information is vital to avoid potentially grave errors. The added advantage of an EHR is the potential to provide seamless care between different healthcare settings and practitioners, to analyse the data across a hospital to improve safety in all divisions, and even to combine data across a region or country for improved Public Health surveillance and control, e.g. of infectious diseases.

User-friendliness and acceptance

Dr. Thierry is fully aware that the main challenges in the deployment of patient safety technology concern the user-friendliness of the application, and the acceptance by clinicians.

“A common problem of Decision Support Systems is that clinicians tend to get too much information and too many warnings. The result is that they simply override or switch off the alerts.”

Current work to address this issue focuses on making the alert system more adapted to human cognition. For example, alerts can be provided in a hierarchical way, following a traffic-light system. Another problem with Decision Support Systems is knowledge validation, which is partially related to the artificial character of evidence-based medical knowledge. The inclusion criteria for patients in randomised controlled clinical trials produce evidence suited predominantly for a specific type of patient, for example one of a certain age, diabetes of type II and no prior history of smoking or overweight. In real life, doctors are confronted with patients who are multimorbid, chronically ill and do not easily fit the evidence reproduced in guidelines.

Other challenges in the deployment of patient safety tools such as an EHR concern a lack of standardised technology. This prevents integration and interoperability of information systems, and severely limits the ability of EHRs to facilitate continuous, informed care across healthcare settings.

A few implementation guidelines

Before implementing any eHealth solution, a stringent analysis of the objectives and outcomes expected, the benefits to be derived, and the challenges to be overcome is mandatory.

“The new ICT tools need to be adequate to meet the needs identified, and should provide clear benefits to all involved, particularly to the clinicians who have to use them daily,” explains Dr. Thierry.

The main challenges – well known also from innovation research – are continuous change management, involvement of all stakeholders when planning the introduction of new eHealth systems, adequate training of all concerned, transparency of all changes being made, and continuous evaluation and adaptation of the application in a pragmatic fashion.

In summary, ICT is an enabler that will revolutionise future healthcare processes, and a key component of a safer healthcare environment. However, it is only one component, and man-agement and cultural issues deserve the same attention.

“Moreover, a holistic vision and strategy which also takes into account organisational factors is mandatory if safety is to be strengthened for all - be they healthy citizens or patients in need of service,” adds Dr. Thierry.

Dr. Jean-Pierre Thierry is a specialist of biomedical and healthcare information technology, with over 20 years experience in consulting and project management for the industry as well as for governments and hospitals. He has worked for several professional organisations at a national level in France, such as the National Medical Board, National Centre for Hospital Equipment, and Centre for the Study of Advanced Technology. Dr. Thierry has also held positions as CIO of two large general hospitals in the Paris area. He currently works as an IT expert for the National Agency for Hospital Investment and for the French region of Picardie. With Dr. Veli Stroetmann he coordinated a study for the European Commission on the impact of ICT on patient safety and risk management in healthcare (eHealth for Safety).

ePrescribing has a key role to play in improving the quality of healthcare through promoting patient safety. Mary Griskewicz, HIMSS Director of Ambulatory Information Systems explains some of the benefits achievable through ePrescribing, and some of the challenges faced.

“The simple process of writing a prescription is probably the single most common action under-taken by physicians. In UK alone, 720 million prescriptions were written in 2005; an increase of 5% over the previous year. Yet we all have stared at a physician’s handwritten prescription and wondered how the pharmacist is going to decipher it.

“It’s a very serious matter: errors in prescribing can be catastrophic – and all too frequently are. The US-based Agency for Healthcare Research and Quality estimates that 770,000 Americans are injured or killed by medication errors each year. In the UK, the publication ‘Building a Safer NHS for Patients – Improving Medication Safety’ cites ePrescribing as a key step for reducing medication errors. A report by a patient safety group estimates that ePrescribing would reduce medication-related errors by 86%.

Enhanced efficiency and communication

“Other benefits are also possible. An effective ePrescribing system can make it easier for alerts to show up for allergic reactions and contra-indications. ePrescribing may increase the use of generic medications and reduce costs.

“Moreover, a whole host of process improvements are possible, such as a clearer audit trail of medication administration; enhanced communication between different care providers; and more efficient inventory control of pharmacies.

“ePrescribing is also one of the integral steps to achieving broad deployment of the Electronic Health Record. The inclusion or integration of medications prescribed in an Electronic Health Record and Personal Health Record is paramount in improving patient care.

“Commercial software to support ePrescribing is becoming more widely available. ePrescribing has the advantage that it is fairly straightforward to deploy, and implementation can be per-formed modularly. In the UK, implementation of an ePrescribing service forms part of the NHS Plan. Its ePrescribing project focuses on primary care prescribing and forms a part of Connect-ing for Health. ePrescribing pilots went live in early 2005, and the deadline for full implementa-tion of the service in the NHS has been set at December 2007.

Barriers still to be overcome

“The benefits of ePrescribing may look convincing, but adoption remains modest. Surveys con-ducted in the US estimate that between 5% and 18% of physicians and other clinicians are us-ing electronic prescribing, with EMEA levels somewhat lower – or non-existent in some coun-tries.

“Barriers to clinician adoption include startup cost, lack of specific reimbursement, and fear of reduced efficiency in the practice. Physicians also need to have the appropriate technical exper-tise (or staff) to understand the technology and implement it correctly. The cost and time of training is another challenge to be faced.

“On top of these are the legislative barriers. Countries have to look closely at their national leg-islation to see if ePrescribing fits their current healthcare plans and remit. This is certainly the case for France, where current legislation does not allow ePrescribing. Patient confidentiality is another issue; whenever personal health information is automated, appropriate safeguards have to be put in place.

“However, despite the challenges and barriers, ePrescribing is essential to improve patient safety and quality of care – the potential benefits to patients and providers are huge. Its adop-tion should therefore be encouraged through the deployment of appropriate incentives.”

"How can I get involved in IHE?"

Last month’s eMessenger focussed on the topic of Integrating the Health Enterprise (IHE). One reader asked how he can get involved in the activities of IHE, and in particular the IHE IT Infrastructure Planning Committee described by Charles Parisot in Expert View. Below are a few suggestions.

To know more about IHE and especially the IT Infrastructure Domain:

• Participate in the upcoming IHE IT Infrastructure Domain Public Comment review of new profiles between 10 June and 10 July. To contribute, access the IT Infrastructure section of www.ihe.net/technical_framework and retrieve the documents; instructions are included.
• Read Volume 1 of each domain’s framework where each Profile is introduced. To receive e-mail highlight updates on IHE, and in particular the Public Comments announcements, regis-ter to IHEnews by sending a request to ihe@rsna.org
• Follow the work of a specific IHE Domain, by a simple email request to the selected IHE Domain Planning and/or Technical mailing lists. For IT Infrastructure, contact ihe@himss.org.
• Register your product for testing at the next IHE Europe Connectathon at http://ihe.univ-rennes1.fr/organization/news.php (Click on “Planned Demonstration for 2007”)
• Contact the IHE European Office

Cordula Singer
HIMSS EMEA secretariat

Questions anyone?
Challenge us to help you with your (healthcare ICT related) questions. Send your input to emea@himss.org (subject line: question time) and we will research and publish your questions and our answers in forthcoming issues of the eMessenger.

The HIMSS Mission

The Healthcare Information and Management Systems Society (HIMSS) is the premier professional member organisation exclusively focused on providing leadership for the optimal use of healthcare information technology.

The HIMSS mission is to lead change in the healthcare information and management systems field through knowledge sharing, advocacy, collaboration, innovation and community affiliations. HIMSS EMEA brings this mission to Europe, Middle East and Africa.

HIMSS EMEA

HIMSS in Europe, the Middle East and Africa (EMEA) is dedicated to bringing together all the major players in the Health ICT community to transcend borders and languages and engender a truly regional dialogue. As members of HIMSS EMEA, individual professionals (managers, administrators, clinicians, technology experts and users), vendor companies and IT providers meet, interact and learn from one another.

With the opening of its EMEA office in Brussels, HIMSS is now positioned to provide activities, programmes and education specifically designed for the EMEA Health ICT community. Guided by a Governing Council of members from within the EMEA region, HIMSS EMEA focuses on the needs of individual and corporate members to ensure dedicated services and membership value.

Membership benefits include

• A monthly e-newsletter - HIMSS EMEA eMessenger – delivered to your inbox on the third Thursday of every month.
• A series of educational eSeminars on topics reflecting the challenges of the Healthcare ICT community in the EMEA region. Following April’s successful inaugural eSeminar on Electronic Health Record systems, HIMSS EMEA is planning a challenging programme for the coming months, which covers hot topics like Privacy Protection and Patient Safety. For detailed information, please have a look at the schedule for 2007.
• An interactive website targeted at the main issues and experts within our community. This includes a weekly “Expert View” on the issues that matter to you as well as industry news (RSS feed in partnership with Healthcare IT News Europe).
• Access to the latest industry and policy documents on the HIMSS EMEA online resource centre.
• Significant member discounts on the World of Health IT Conference and Exhibition, the HIMSS Annual Conference & Exhibition, the HIMSS bookstore and HIMSS events.

To learn more about HIMSS EMEA take a look at our website: www.himss.org/emea