Engineering a Learning Healthcare System A Look at the Future: Workshop Summary (2011) / Chapter Skim
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5 Fostering Systems Change to Drive Continuous Learning in Health Care
5 Fostering Systems Change to Drive Continuous Learning in Health Care
Pages 237-270
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From page 237... ...
is "the development of a learning healthcare system that is designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care" (Charter pp.
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From page 238... ...
Swensen, director of quality for the Mayo Clinic and professor of radiology at the Mayo Clinic College of Medicine, said the healthcare industry must address specific elements of technology management in order to drive systems change. He described work in technology management at the Mayo Clinic to develop networks that embody optimal reliability, permit nimble and effective diffusion of best practices, have built-in safety nets, and support optimal organizational learning and communication.
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From page 239... ...
Classen, a physician at Computer Sciences Corporation, described current approaches to the evaluation of clinical information systems. He detailed a new simulation tool that has been developed and used by healthcare organizations to evaluate the effectiveness of clinical information systems implementations in improving the safety of care for patients.
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From page 240... ...
The proposition is not based on hypothesis or conjecture, but is supported by good clinical evidence. This paper begins by examining what needs to be done and in particular, the lessons healthcare organizations can learn from other complex, high-performing organizations in other industries so as to achieve the goal of better care for more people at less cost.
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The playing field is extraordinarily level. And when the playing field is level, this parity of rules can be expected to lead to a parity of outcomes.
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Not only has Toyota grown, but if one looks at the ratios, the market expects it to continue to grow at a sustained rate over many years. One might think Toyota is an anomaly and decide to look at another playing field -- say, commercial aviation.
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A key difference between the highly successful organizations and the others is that the others tolerate, encourage, and depend on an environment where fighting fires, working around problems, coping, and otherwise making do is how work is accomplished. The problem with that approach for the people who work in those organizations is it means that every day they know they are going to go to work and fail to some degree.
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From page 244... ...
I also got involved in the Pittsburgh Regional Health Initiative. Our first effort in Pittsburgh was to look at medication administration.
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From page 245... ...
This paper looks briefly at some relevant IOM work and a project that the AMIA carried out for the Office of the National Coordinator on Clinical Decision Support, and then offers some ideas about what a national roadmap for knowledge management should look like. The 1991 IOM study Computer-Based Patient Record: An Essential Technology for Health Care (reissued in 1997)
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From page 246... ...
. From the perspective of a policy background, a national roadmap for knowledge management with decision support is clearly lacking.
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From page 247... ...
Many pilot demonstrations are recommended, including supporting and facilitating related nationwide initiatives, developing practical standard formats to share knowledge and interventions, and collecting and disseminating best practices for usability and implementation.1 Looking at current policy and national structure, one can see that the roadmap has had an impact. AHRQ is supporting some activities through its national resource center and Centers for Education and Research on Therapeutics grants, including knowledge management CDS grants.
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From page 248... ...
The AMIA recently conducted a survey of the top research issues for informaticians, and the results showed this order of importance: interoperability, workflow, quality and patient safety, decision support, and information filtering and aggregation. The emphasis on interoperability is probably no surprise, but more interesting perhaps is the attention to workflow and process design.
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From page 249... ...
Context awareness of decision support technology needs to be improved. Ultimately, this technology needs to reach the patient through secure Web portal integration, and patients need to be encouraged to work on monitoring and managing their own health care.
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Policy Public policy and health insurance programs are powerful drivers of technology management. Choices about what is incentivized and paid for play a central role in determining what is performed and prescribed.
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Here is an important role for a common outpatient/inpatient EHR (and the instant peer review and communication it affords) , standard order sets, decision support, and clinical prediction rules.
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Optimal management of technology must include attention not just to its appropriateness, but also to the reliability of its use. Diffusion Effective and efficient technology management to support highreliability patient care requires a nimble and effective diffusion of best practices as well as safety nets, both within an organization and nation
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From page 253... ...
. Social engineering is an important dimension of high reliability and is requisite for optimal technology management.
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The hospital is viewed not as a centerpiece, but often as the safety net for insufficient chronic and preventive outpatient care. Technology management should be approached in a manner that leverages and creates social capital.
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. This paper reviews current approaches to evaluating the contributions of EHR systems to improving clinical performance and describes a new simulation tool that is designed to help organizations evaluate the effectiveness of currently implemented EHR capabilities in meeting quality and safety goals.
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. This finding explains the priority placed on computerized physician order entry (CPOE)
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From page 257... ...
The Leapfrog Group's standard requires physicians and other licensed prescribers to enter more than 75 percent of medication orders electronically, and it also requires that CDS be capable of intercepting at least 50 percent of common, avoidable adverse drug events (Kilbridge et al., 2006b)
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From page 258... ...
System use monitoring EHR-provided reports Provides information about use of order sets and instances of, and responses to, clinical decision support Evaluation study Research study exploring Documents the type hypotheses about potential and extent of change in impacts of CPOE and other hypothesized change areas applications that build the inpatient EHR Measurement of Process and outcomes Provides evidence of performance measures concerning the combined effects of inpatient care improvements in clinical practice and processes, including use of information technology when applicable preventable medication errors that harm patients (The Leapfrog Group, 2008)
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From page 259... ...
In every hospital where the evaluation tool has been employed during its long development process, the physician CPOE leaders and other team members have gained knowledge about gaps in CDS coverage of important order categories in addition to confirming what some already knew about CDS usage. The increased insight now available to other hospitals through use of the CPOE simulation tool promises to spur significant progress on the long journey that remains until the full potential of CPOE is realized to help prevent medication-related adverse drug events.
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From page 260... ...
test or full evaluation, sign on to the Web application • Print the list of test patients • Set up test patients • Ensure that patients are "active" (may require nursing unit and bed before orders can be written and signed) • When ready to begin the sample test Download test orders or full evaluation, sign on to the Web application • Print test orders, instructions, and answer sheets • Ensure that the physician performing the evaluation has system authorizations required for order entry in CPOE (may be a test user)
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From page 261... ...
• Sign on to the Web application Enter and submit results • Submit information from the answer sheet as instructed • Use automatic scoring of success in Scoring providing decision support to avert common, harmful medication errors for each order category and the evaluation overall • Print or view the feedback report Reporting immediately available (scores for each order category) • Aggregate the score available for posting along with hospital survey results SOURCE: Reprinted with permission from Patient Safety & Quality Healthcare.
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From page 262... ...
22 ENGINEERING A LEARNING HEALTHCARE SYSTEM TABLE 5-3 Medication Order Categories in the Leapfrog Computerized Provider Order Entry Evaluation Order Category Description Examples Therapeutic duplication Medication with Codeine and Tylenol #3 therapeutic overlap with another new or active order; may be same drug, within drug class, or involve components of combination products Single and cumulative dose Medication with a Ten-fold excess dose of limits specified dose that exceeds Methotrexate recommended dose ranges or that will result in a cumulative dose that exceeds recommended ranges Allergies and cross-allergies Medication for which Penicillin prescribed for patient allergy has patient with documented been documented or penicillin allergy allergy to other drug in same category has been documented Contraindicated route of Order specifying a route of Tylenol to be administered administration administration (e.g., oral, intravenously intramuscular, intravenous) not appropriate for the identified medication Drug–drug and drug–food Medication that Digoxin and quinidine interactions results in a known, dangerous interaction when administered in combination with a different medication in a new or existing order for the patient or results in an interaction in combination with a food or food group
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From page 263... ...
2 FOSTERING SYSTEMS CHANGE TABLE 5-3 Continued Order Category Description Examples Contraindication/dose Medication either Nonspecific beta blocker in limits based on patient contraindicated based patient with asthma diagnosis on patient diagnosis or diagnosis affects appropriate dosing Contraindication dose Medication either Adult dose of antibiotic in a limits based on patient age contraindicated for this newborn and weight patient based on age and weight or for which age and weight must be considered in appropriate dosing Contraindication/dose Medication either Normal adult dose regimen of limits based on laboratory contraindicated for this renally eliminated medication studies patient based on laboratory in patient with elevated studies or for which creatinine relevant laboratory results must be considered in appropriate dosing Contraindication/dose Medication contraindicated Medication prescribed known limits based on radiology for this patient based on to interact with iodine to studies interaction with contrast be used as contrast medium medium in recent or in ordered head computed ordered radiology study tomography exam Corollary Intervention that requires Prompt to order drug an associated or secondary levels when ordering order to meet the standard aminoglycoside of care Cost of care Test that duplicates a Repeat test for digoxin level service within a time frame within 2 hours in which there are typically minimal benefits from repeating the test SOURCE: Reprinted with permission from Patient Safety & Quality Healthcare. Metzger et.
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From page 264... ...
Other groups took a pragmatic approach to the question of how much more value could be obtained and based their estimation on the figures presented during the workshop, which had suggested the existence of up to 50 percent waste in the current system. Based on this, they concluded that it was reasonable to assume that a doubling of value was attainable through the application of systems engineering principles.
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From page 265... ...
being done in pharmacy application, but not delivered to physicians Actions Taken • Evaluated order categories in simulation tool against local experience (phar macist interventions) to assign priorities for advancing clinical decision support (CDS)
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From page 266... ...
Participants mentioned the need to overcome barriers created by the current culture in order to allow for more integrated care; reforming the models of education for healthcare providers would be one way to approach this problem. The need for greater collaboration between process engineers and medical professionals was also mentioned as an area for action in achieving higher value from health care.
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The impera tie for computerized physician order entry in Massachusetts hospitals. Cambridge: Massachusetts Technology Collaborative and New England Healthcare Institute.
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From page 268... ...
2005. Unexpected increased mortality after implementation of a commer cially sold computerized physician order entry system.
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2006a. The national quality forum safe practice standard for computerized physician order entry: Updating a critical patient safety practice.
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2008. Effect of computer order entry on prevention of serious medication errors in hospitalized children.
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