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Kathleen Covert Kimmel, RN, MHA, CHE Joyce Sensmeier, MS, RN, BC, CPHIMS
Despite having unparalleled technology and resources, the US healthcare system has room for improvement. Impressive advancements in medical knowledge have accelerated at a mind-boggling rate, but knowledge and information distribution are ineffective and not readily available to the majority of providers. Innovative surgical procedures using advanced technology diagnostic equipment offer a sophisticated understanding of a patient's condition, but information distribution and communication is hampered by the manual, paper-based patient charts in most hospitals. The multiple people, departments, and processes that are an integral component of effective and efficient patient-centered care are typically lacking. Handwritten medication orders are error prone. Indeed, deciphering handwriting is frequently a challenge for those processing orders. Medications with similar names, but different action classes, effects, and dose ranges further complicate the medication management process. The good news is that there are technologies available to rectify these challenges. Decision support systems offer the latest recommended clinical knowledge to assist clinicians as they evaluate, diagnose, and treat patients. Integrated, enterprise-level electronic medical records offer real-time access to clinical notes, procedures, test data, vital signs, allergies, medication history, and other medical information to the entire gamut of caregivers. Computerized physician KEYWORDS
Electronic Medical Record Computerized Physician Order Entry Clinical Decision Support Systems Clinical Workflow Processes Adverse Drug Events Patient-Centered Care Bar Code Technology Hand-held and Wireless Devices The Institute of Medicine The Leapfrog Group
order entry (CPOE), combined with sophisticated alerts, can detect potential negative drug interaction dosage irregularities, conflicts with other medical problems, etc., and can greatly reduce errors. Computerization in the clinical setting has focused on singlepurpose applications. The proliferation of computerized clinical applications created an awkward collection of systems wherein pieces of patient data were stored in a variety of silos. As technology advancements occurred, new systems were often stacked on top of the old. Although this was originally intended to preserve familiar work processes, adding layers of functionality to already cumbersome and isolated legacy systems was similar to building a house of sticks — under the weight of additional layers the system began to crumble and collapse. The work processes related to these systems became burdensome and enhanced the potential for errors. It is time for hospitals to take stock of their technology and applications and evaluate clinical workflow. If technology is applied to an inefficient manual process, it will retain its inefficiencies when automated. Technology, combined with clinical process transformation, holds the most promise for improvement. Given the expense of an electronic medical record system, which includes physician order entry, medication administration records, and decision support systems, funding from the hospital supplemented by the federal government is needed. The events of September 11, 2001, and the subsequent threats of bioterrorism, have placed a spotlight on the inability of our nation's local healthcare delivery model to rapidly move patient-specific and organism/treatment-related
Healthcare Information and Management Systems Society ©2002
consider providing financial incentives to hospitals that adopt CPOE systems.5 million to skilled-nursing facilities each year.1 In November 1999. • providing greater legal protection for data collected for patient safety and quality improvement purposes.3 A Medicare Patient Advisory Commission report suggested that the Centers for Medicare and Medicaid Services (CMS). • achieving acceptable levels of patient safety will require major systems changes. Uncovering the degree of the problem was fueled by the medical error-related death of Boston Globe health columnist Betsy Lehman in 1994. • errors result from system failures. In May 2001. The AHRQ produced a report.5 State governments have also responded to the IOM report. not people failures. the Committee on the Quality of Care in America produced a second report. the State of California passed a bill mandating that all non-rural hospitals implement CPOE by 2005." This report presents a call for action to improve the US healthcare delivery system." This report shocked the nation by exposing a quality crisis.) and Olympia Snowe (R-Maine) introduced legislation to provide grants to hospitals and nursing facilities to implement technology that reduces medication errors. including medications and safety-oriented approaches. formerly known as HCFA.A Technological Approach to Enhancing Patient Safety data between and among hospitals and private physician practices. The IOM report recommendations set a 50 percent reduction in medical errors as a goal within five years.4 The Agency for Healthcare Research and Quality (AHRQ) received $50 million to fund error-reduction research. So.000. Lehman. the government needs to create a national health information infrastructure as a medical communication highway to protect its citizens. with $93 million available to hospitals and $4. this report galvanized strong reaction from both the private and public sector. • encouraging voluntary reporting. President Clinton ordered a governmentwide feasibility study. Just as the government built the national highway system after World War II because the existing road system was inadequate to move large numbers of troops rapidly across the country. The Medication Errors Reduction Act of 2001 calls for nearly $1 billion in grants during the next 10 years. the government has continued to address the problem. 2 In March 2001. which could be achieved by: • creating a Center for Patient Safety. instead of the daily dose for four days. stating that between 44.000 and 98. For example. The overdose caused heart failure. • promoting performance standards (people and organizations) that emphasize safety. • mandating a reporting system for medical errors.6 In the almost two years since the first report. and • a concerted national effort is needed to improve patient safety. Under the bill. individual hospitals will be eligible for grants of up to $750. Healthcare Information and Management Systems Society ©2002 . mistakenly received the cumulative dose of the cancer drug Cisplatin. the Committee on the Quality of Care in America produced a report titled "To Err is Human: Building a Safer Health System. "Crossing the Quality Chasm: A New Health System for the 21st Century. meetings. who was being treated for breast cancer at Boston's Dana Farber Cancer Institute. for many years. which represented a first effort to approach the field of patient safety through the lens of evidence-based medicine. which was followed in February 2000 by a presidential mandate to implement the IOM recommendations—specifically to reduce medical errors by 50 percent in the next five years.000 hospitals participating in the Medicare program to implement patient-safety initiatives. Post-event findings and analysis culminated in the release of the Institute of Medicine's (IOM) first report. Within two weeks after the release of the first IOM report.2 The Public Sector's Response to the First IOM Report Although there continues to be great debate about the actual number of errors. "Making Healthcare Safer: A Critical Analysis of Patient Safety Practices" in July 2001. Her death triggered a landslide of government hearings. with grants for nursing facilities capped at $200. including information-related strategies. DESCRIPTION OF THE ISSUE Processes to detect and reduce medical errors in hospitals and healthcare systems have been hampered by the lack of integrated technology and decision support applications. the US Congress began a series of hearings. Senators Bob Graham (D-Fla. The report concluded that: • the extent of harm that results from medical errors is great. the extent of medical errors was unknown.000.000 hospital deaths each year are related to preventable medical errors. and • emphasizing safe use of drugs through the FDA. and reports. The President's mandate requires all 6.
Seattle. medical history. Originally Leapfrog focused on encouraging providers to voluntarily adopt their recommendations. Minnesota. As of January 1.13 The Second IOM Report: Crossing the Quality Chasm The second IOM report decries a medical system where physician groups. will get the attention of pharmacists. The Leapfrog Group. marketplace incentives to encourage the healthcare sector to adopt systemic quality improvement processes. General Motors was to have rewritten all of their payer contracts to require them to include patient safety requirements within their hospital provider contracts. The information will be available to millions of hospital-seeking beneficiaries via the Leapfrog Web site. hospitals in Empire Blue Cross and Blue Shield's networks receive a four-percent bonus for meeting two quality standards — CPOE and ICU staffing with intensivists. physicians certified in critical care medicine). has grown from an original membership of 60 purchasers to more than 90 and now represents 25 million beneficiaries. It is hoped that using a combination of eye-catching changes.and lower-case as well as different colored letters. a major health plan began attempting to encourage compliance by presenting financial rewards to providers who meet the safety standards. Hospitals that meet this standard beginning in 2003 willreceive a three-percent bonus. and other organizations "operate as silos. or medications prescribed by other physicians. $15 million has been appropriated for rural hospitals and designated for medical errors reduction and systems improvement to comply with provisions of the Health Insurance Portability and Accountability Act. Louis)."14 Harking back to their first report.7 The Food and Drug Administration (FDA) is implementing changes for the labeling of existing drugs. FDA workers will begin testing groups of volunteer physicians. the private sector has also responded to the first IOM report. The second report provides starter-set information for hospital decision makers to help them organize their CPOE effort and launch the search for an appropriate CPOE solution. and St. stating that the cause is a system that "relies on outmoded systems of work. Three Fortune 500 companies joined Empire Blue Cross to recognize and reward hospitals that achieve the Leapfrog safety standards. often providing care without the benefit of complete information about the patient's condition. Approximately 900 hospitals in seven targeted markets 3 around the country (Atlanta.12 This action puts the onus of responsibility of obtaining provider compliance with the health plans. a coalition of many of the nation's leading companies sponsored by the Business Roundtable.A Technological Approach to Enhancing Patient Safety The Fiscal Year '02 Appropriations Bill includes a 10 percent increase in funding for the Department of Health and Human Services. Eastern Tennessee. 2002. and how many open heart surgeries they perform each year. • refer patients undergoing certain high-risk procedures to high volume hospitals). the Leapfrog Group.11 The Leapfrog Group's efforts to impose economic sanctions to drive compliance are coming to fruition." Healthcare Information and Management Systems Society ©2002 . and those that wait until 2004 will receive a two-percent bonus. are being asked how they process medication orders. The Private Sector Response to the First IOM Report In addition to government agencies. In fact. seeks to create meaningful.. Leapfrog began taking action by using its economic clout to influence provider acceptance of the three recommendations. In fact. including a mix of upper. as well as testing new drugs before they hit the market. and • staff ICUs with intensivists (i. with $55 million set aside for AHRQ to determine ways to reduce medical errors. services provided in other settings. nurses. hospitals. by yearend 2001. The Leapfrog Group has identified three initial patient safety standards as the focus for consumer education and information and hospital recognition and reward: • reduce medication prescribing errors using CPOE. The employer marketplace is responding to Leapfrog's message. In June 2001. joined recently by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).8 Mix-ups with lookalike or sound-alike drug names are a major source of medication-caused injuries and death. and pharmacists about potential confusion of new drug names before the drugs hit the market. this report again addresses patient safety problems.9 The Leapfrog Group and First Consulting Group have released two new reports on CPOE. staff their ICUs. Michigan.e. Additionally.10 Leapfrog's report card-like summary of a hospital's IT infrastructure is expected to help spark action by many providers. California. In addition. Financial analysts are anticipating a profound impact to healthcare IT spending as employers begin to shift market share toward providers who adopt Leapfrog's patient safety standards. The first report is a guide to help hospitals assess the effectiveness of their CPOE systems in intercepting erroneous medication orders. Recently.
16 How extensive are medical errors? The National Committee on Vital and Health Statistics (NCVHS) reports 4 the following statistics: • One in 25 hospital admissions results in an injured patient. including the use of information technology to support clinical and administrative processes. The Centers for Disease Control and Prevention (CDC) recently announced a collaborative effort with the E-Health Initiative to develop a much needed information technology infrastructure to combat bioterrorism. The final category. are studied.3 million injuries occur from medical treatment in the United States. falls.” Recommendations on Restructuring the US Healthcare System The report includes 13 recommendations for restructuring the US healthcare system.000 unnecessary deaths and 1. of these. which account for more than 25 percent of all adverse hospital incidents. The report also requests the AHRQ to facilitate further thinking by convening workshops designed to promote guidelines in specific topic areas. These areas include redesigning care practices. is another source for information on medical errors. The Advisory Board Company in Washington. • Three percent of adverse effects cause permanent disabling injury. pharmacies. the largest single category of medical errors. and settings over time. may be related to provider training or experience and hospitals' infection control policies and procedures.15 DISCUSSION/ANALYSIS Medical Error Statistics The IOM's first report not only highlighted the number of deaths in hospitals due to medical errors. The initiative joins the CDC with a consortium of healthcare IT vendors and organizations that will link legacy IT systems in hospitals. the following results are found: • 56 percent are attributed to physicians. This effort is an important first step in facilitating the capture of critical data at the point of initial contact and transmitting disease surveillance information to the government. • six percent are attributed to unit secretaries. and labs with the CDC National Electronic Disease Surveillance System (NEDSS).18 The second and third categories.19 ADEs. and 40 percent of nurses make mistakes more than 30 percent of the time. Additionally. it also estimated the costs generated by those errors.C. National healthcare costs attributable to those deaths were estimated to be $8 billion annually. • 60 incidents are due to nosocomial (hospital-acquired) infections. and • four percent are attributed to pharmacy staff. Adverse drug events (ADEs) top the list in frequency of occurrences. because 40 percent of all care is directed toward chronically ill patients.700 per admission. and • 15 incidents are due to falls. Also included are recommendations for mutual efforts between payers and providers to work toward a care system where patients and providers cooperate. and coordinating care across patient conditions. services. • About 23. • 51 incidents are due to procedural complications.. including elderly patients. Each category is listed along with the number of times they occur per 1. is usually related to unstable patients. The average cost of an ADE is $4. While some recommendations pertain to quality of care.000 hospital patients die each year from injuries linked to medication use. D. • 80 percent of nurses calculate dosages incorrectly 10 percent of the time.000 hospital visits: • 65 incidents are due to adverse drug events. and share information that is current and evidence-based. high-quality care is to "redesign systems of care. using information technologies to improve access to clinical information. • Approximately 180.17 Besides the IOM and the NCVHS. can be Healthcare Information and Management Systems Society ©2002 . others discuss funding for monitoring and tracking existing solutions for quality of care. and can be traced to policies and procedures. supporting clinical decision making in an electronic environment. one in seven leads to a patient death. collaborate. • Preventable medical errors account for 12 to 15 percent of hospital costs. When ADEs. nosocomial infections and procedural complications. • 34 percent are attributed to nurses. The Advisory Board divides adverse effects into several categories. ADEs have a wide range of causes and careful measurement is a complex process.A Technological Approach to Enhancing Patient Safety The solution for safer. there are recommendations to identify at least 15 of the most prevalent chronic diseases and to develop strategies for improving quality of care for each.
25 A more recent study presented at the 2001 Annual HIMSS Conference and Exhibition provides evidence from Montefiore Medical Center. This figure combines the time savings for nurses. and applying existing information. The solution to reducing the number of medical errors resides in developing mechanisms for collecting.511 2. stated. practice standards. An early study at an academic medical center estimated that CPOE generated savings of $5 to $10 million annually on a $500 million budget.8% productivity. The good news for hospitals is that positive return-on-investment data related to some of these technologies already exists.9 $164. CONCLUSIONS/RECOMMENDATIONS/POSITION STATEMENT The Role of Technology A common theme throughout the IOM reports is the critical role information technology plays in reducing medical errors. and computerized decision support. The results indicate that the "most wired" hospitals. and more efficient utilization management than their peers. 241 per discharge $4. transmission. and Education of the Senate Committee on Appropriations. namely hospitals that have embraced technology solutions. These Healthcare Information and Management Systems Society ©2002 .400 per year/per practitioner to calculate the savings in an ambulatory environment.20 While technology is a critical component to patient safety management. create. In his statement before the subcommittee on Labor.8 113. and pharmacists. If we are going to make significant strides in enhancing patient safety. and trending. a 1. Traditional workflows must be re-evaluated to harness technology and assist in information capture.3 $423.A Technological Approach to Enhancing Patient Safety immediately influenced by information technology. it should also be a part of an organization-wide strategy that includes workflow process redesign. Systems can be integrated and processes automated without solving the problem.73 days 15% 3. medical vocabularies.100-bed academic health system. president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). unit-of-use bar coding to reduce medical errors and improve productivity. analyzing.28 According to a report from Cerner Corporation.780 per discharge $3. This report produced a formula for calculating the amount of savings per year/per physician by multiplying $41. flow."21 The Healthcare Information and Management Systems Society (HIMSS) is advocating for the use of information technology including point-of-care.30 Technology is rapidly progressing. CPOE and bar code medication administration are two proven technology-supported work processes that can reduce medical errors in three of the categories listed above. have better control of expenses. and disseminate. Samaritan Regional Medical Center saved $3 million annually and avoided 36 deaths by using a computerized data repository that was populated with medication rules. purchasing this technology requires 5 a demonstrable return on investment.29 A 1998 study by the Gartner Group estimated a positive return on investment for ambulatory computer-based patient records. unit secretaries.3 90. functions. and capabilities.24 days 35% 3. "Medical error reduction is fundamentally an information problem. higher Table 1. Dennis O'Leary. Electronic medical records with decision support at the time of order entry are improving each year in their features. which has seen a system-wide 75 percent reduction in medication errors since implementing bar code medication administration software.995 0.6% Other Hospitals Average length of stay Highest AA credit rating FTEs per occupied bed Paid hours per adjusted discharge Net patient revenue Expenses per adjusted facility discharge Annual increase in expenses 3. of tremendous savings for CPOE and medication administration record — roughly $6 million annually. Return on Investment Data Substantiates the Value of Investing in Technology 27 Attribute Technologically Advanced Hospitals 3. Decreasing the number of ADEs requires the combination of clinical workflow transformation along with selective implementation of technology.22 Evidence of the impact of technology is demonstrated by the Veterans Health Administration. Health and Human Services.26 Table 1 uses data from the 2001 Hospitals & Health Networks third annual survey.24 Economic Justification for Information Systems Technology Given the significant capital restraints now burdening healthcare organizations. we must think in terms of the information we need to obtain. physician order entry.23 The American Medical Informatics Association also contends that errors can be prevented by computer systems that provide electronic patient records. analysis.
session 17. Utilizing CPOE.org/advocacy/about/advocacy. Burdick E. Medical Errors: Sources and solutions. www. Modern Healthcare. healthcare in this nation and all over the world will be vastly improved. This can only be achieved when this information is available through decision support capabilities at the time of order entry.html. Committee on Quality of Health Care in America. Patients must be informed decision makers and active participants in their care. Wachter RM. Orders and results need to be immediately available to the physician. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. 17 National Committee on Vital and Health Statistics. September 6. 7 Healthcare Information and Management Systems Society. McDonald KM. Minding hospitals' business: Purchasing coalition pushes hospitals to improve patient safety through process measures. 280:1311-1316. The reference laboratory must supply results that offer guidance in the interpretation of the test and support the physician in selecting additional tests or proper treatment. National Academy Press.org/about/advocacy. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Health plans need to provide the ordering physician with information on disease state management. July 20. and pharmaceutical companies — is required. 16 Beers JB. http://www. The Advisory Board Company.asp 1 2 6 Healthcare Information and Management Systems Society ©2002 . laptop. as well as receive decision support while processing them. 2001. Vander Vliet M. 2001. 2001. Proceedings of 2001 Annual HIMSS Conference and Exhibition. 2001. 2001. Overview of the Leapfrog Group Evaluation Tool for Computerized Physician Order Entry. February 22. 20 Beers JB.C. Orders may be entered using a hand-held device. 11 Falci RG. D. An Update on the Leapfrog Movement: A Macro Catalyst is Maturing into a Fundamental Change Agent. Duncan BF.asp. 19 Clinical Initiatives Center Prescription for Change. and Seger DL.gov 4 Medicare Payment Advisory Commission. FDA implementing changes with new labels. Laird N. 1875. but industry says standards are too expensive. and nurses to enter patient data at the patient bedside. January 18. Classen D. February 22. 21 O'Leary D. 2001. Bear Stearns Equity Research White Paper. Statutes of 2000. Berger MA.org/govt/oleary_02220. other ordering clinicians.himss. 14 Ibid. Advocacy Dispatch..A Technological Approach to Enhancing Patient Safety systems are justifying themselves in saving lives and money. December 24. 2000. January 2. 2001. Accessibility to mobile computing devices at the point of care is evolving. Leape LL. 13 Media Release Three fortune 500 companies join Empire Blue Cross and Blue Shield to recognize and reward hospitals that achieve Leapfrog safety standards. National Academy Press. Weinberger A. physicians are able to review up-to-date patient test results and other pertinent data prior to writing orders. Health and Human Services and Education of the Senate Committee on Appropriations. Berger MA. 2001. October 19.jcaho. Institute of Medicine. 1998. Report to Congress: Selected Medical Issues. Shea B. June 1999. 18 Bates DW. Senate and the Subcommittee on Labor. References Committee on Quality of Health Care in America. (202) 672-5290. 5 Shojannia KG. This patient care team also needs to include the patient. June 23-24. and treatments at various stages of the clinical condition. Crossing the Quality Chasm: A New Health System for the 21st Century. 9 Lovern E. Steward RT. 2001 Congressional Review. 12 Ibid. Statement of the Joint Commission on Accreditation of Healthcare Organizations before the U. Advocacy White Paper: Bar Coding for Patient Safety. Healthcare Information and Management Systems Society. When all healthcare stakeholders recognize their responsibility and work together to address the patient safety issues. Institute of Medicine. 2001. AHRQ Publication 01-E058. December 2001.himss. Press Briefing by Senior Administrative Officials on President's Initiative to Reduce Medical Errors. Washington. Now is the time for a call to action for all healthcare stakeholders. 15 Healthcare Information and Management Systems Society. www. 2001. Teich JM. Medical Errors: Sources and solutions. wireless tablet. CDC's ongoing push to create a national bioterrorism early warning system.S. Best Practices for Medication Management. HIMSS NewsBreak. or desktop PC. To Err is Human. May 28.pub. Wireless computing devices enable physicians. Journal of the American Medical Association. 10 Kilbridge P. Kleefield S. the reference laboratory. Cullen DJ. as well as to the entire treatment team at the hospital. 3 The White House Office of the Press Secretary. Leapfrog Group and First Consulting Group. 8 Daily Dose E-Mail. Welebob E. A four-way cooperative alignment between the ordering physician and the three major purveyors of information — the health plan. www. Session 17. 1999.whitehouse. Empire BCBS. Chapter 816. 2002. 2000. Modern Healthcare. 22 Simpson N. Proceedings of 2001 Annual HIMSS Conference and Exhibition. Petersen LA. efficacy of various drugs. Hickey M. Use of bar coding in combination with decision support assures that patients are receiving the correct medication or treatment. Testimony. 6 California Senate Bill No. 2001.
Sensmeier is also a faculty member at Loyola University Chicago. She is a board-certified healthcare executive with the American College of Healthcare Executives. Impact of information events on medical care. 30 Duncan M. photocopying. Journal of the American Informatics Association. adapted. Proceedings of the 1996 Annual HIMSS Conference and Exhibition. The big payback: 2001 survey shows a healthy return on investment for into tech. 26 Manzo J. February 2001. 23 Author Biographies Kathleen Covert Kimmel. Hospitals & Health Networks. All rights reserved.. A simplified financial ROI for an ambulatory CPR. HIMSS. Gartner Group. Cohen M. Taylor RG. She has a BS in nursing from the University of Massachusetts and an MHA from Duke University. Tucker CL. T. 1996. BC. or otherwise. 29 Dennings EH. October 1998. 25 Glaser J. August 2001. Joyce Sensmeier. Cusick D. Kumperman G. Cerner Corporation. 2001. 28 lbid. No part of this publication may be reproduced. 230 East Ohio. Using BCMA software to improve patient safety in Veterans Administration Medial Centers. Measuring medication related ROI an process improvement after implementing POE.org 7 Healthcare Information and Management Systems Society ©2002 . advancement. is a consultant with IBM's Global Services. 46-51. Suite 500. Willette C. Shabot MM. She currently serves as chair of the HIMSS Outcomes special interest group. stored in a retrieval system or transmitted in any form or by any means. mechanical. is the Director of Professional Services at the Healthcare Information and Management Systems Society (HIMSS). Healthcare Management Consultants. Reducing the frequency of errors in medicine using information technology. HIMSS News. Sheridan. Healthcare Industry. 27 Solovy A. without the prior written permission of the publisher. ©2002 Healthcare Information and Management Systems Society. 40-50. MHA. certification. 299-308. IL 60611 Tel: 312/664-4467 Email: publications@himss.A Technological Approach to Enhancing Patient Safety Johnson CL. 24 Bates DW. 2002. Journal of Healthcare Information Management. and the Integrating the Healthcare Enterprise initiative. RN. She is responsible for HIMSS advocacy efforts. 16:1. July 2001. RN. electronic. Carlson RA. Overhage JM. recording. Leape LL. MS. Chicago. translated. Teich JM. June 22.
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