Knowledge Driven Care

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Knowledge Driven Care Realised Through
Transformation

• Dr Simon Wallace
• Medical Executive
• Cerner UK

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Themes of Presentation

• Setting the scene
• Drivers for transformation
• How can IT support change
• Examples of knowledge driven care
• Strategy and Cultural barriers
• A Day in the Life of a Doctor

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Information Overload
The lag between the discovery of more
efficacious forms of treatment and their
incorporation into routine patient care is
unnecessarily long, in the range of about 15 to
20 years.
Institute of Medicine, Crossing the Quality
Chasm, 2001

• 20,000 biomedical journals
• gt150,000 medical articles per month
• gt300,000 randomized controlled
• trials

Source Chassin, M., Millbank Quarterly, Oct,
1998 FIG1
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Knowledge Resources

• Cochrane Library
• Medline
• NICE
• National Electronic Library for Health
• University of York NHS Centre for Reviews and
  Dissemination
• NHS Economic Evaluation Database
• DARE Database of Abstracts of Reviews and
  Effects
• Effective Healthcare Bulletins
• Bandolier evidence based healthcare
• Healthcare Needs Assessment epidemiologically
  based reviews
• SIGN Guidelines - Scotland

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Reasons for Transforming Healthcare?
..excellence of the status quo is a sentimental
illusion. Berwick, Ann Intern Med, 1998
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Reasons for Transforming Healthcare?

• Governments
• UK
• Modernisation Agency For the work modernising
  the NHS to be truly effective, it is essential
  that the current processes and procedures in the
  NHS are reviewed and tangibly and sustainably
  improved through a whole system approach to
  transformational change
• Wanless Report Success or failure of the NHS
  Plan will ultimately depend on how effectively
  the health service uses its resources.
• United States
• In the US by 2007, they will be spending nearly
  17 of their GDP on healthcare (2.1 trillion)

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Reasons for Transforming Healthcare?

• Healthcare organisations
• Provide quality healthcare
• Reduce waiting times DoH targets
• Improve capacity and throughput
• Improved efficiency of resources
• Meet clinical governance requirements
• Provide value for money services
• Information returns

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Reasons for Transforming Healthcare?

• Health Professionals
• Deliver best practice quality care
• Reduce Errors
• Medical documentation at time of consultation
• Improved Communication
• Job Satisfaction

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Reasons for Transforming Healthcare?

• Patient Healthcare Experiences
• (highlighted in the very recent
  Commonwealth Fund report surveying 3849 adults
  across UK, US, Canada, Australia and New Zealand)
• Medication and Medical Errors
• Care Co-ordination Problems
• Doctor-Patient Communication
• Access and Cost Problems

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Iatrogenic injury

• Institute of Medicine (IOM)
• To Err is Human (1999)
• Crossing the Quality Chasm (2000)
• During hospitalization in the US as many
• as a third of patients suffer from complications
  related to their 'care'
• 80,000- 180,000 treatment related deaths in
  hospitals every year
• Apart from treatment deaths another 1.3 million
  people will be harmed
• Between 5 and 13 of hospital admissions result
  from the adverse effects of diagnosis or
  treatment
• 70 of iatrogenic complications, are preventable
  
• Millenson, Demanding Medical Excellence, 1997
  
• Sharpe and Faden, Medical Harm 1998
• Leape, L., JAMA July 5, 2000)

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Adverse Drug Reactions

• Bandolier June 2002 www.ebandolier.com
• Adverse drug reactions (ADRs) in hospital
  patients
• Affects 7 of patients or admissions in England
• Responsible for 4 out of 100 hospital bed days
• Estimated at 15-20 400-bed hospital equivalents
• Consuming 4 of bed days available
• Cost the NHS 380 million per year

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Adverse Drug Reactions

• Factors associated with increased incidence
• Age (especially over 70 years)
• Increasing number of medicines
• Classes of medicines antibiotics,
  anticoagulants, digoxin, diuretics, hypoglycaemic
  agents, and NSAIDs (60-70)
• Economics
• US 777,000 injuries and deaths each year
  costing 5.6 million per hospital (depends on
  size)
• Extra 8-12 days in hospital, 16-24,000 extra
• Prevention
• 25-95 of ADEs prevented using computerised
  monitoring systems
• Computerised order entry has the potential to
  prevent an estimated 84 of dose, frequency and
  route errors

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How to Transform

• The first step to take is Workflow Optimisation

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Errors are inevitable

• A fundamental philosophy emerges
• The most common failures are system errors
  involving drug knowledge dissemination, drug
  dosing, patient identity checking and patient
  information availability, suggesting inadequate
  systems, rather than individual inadequacy, as
  causes for error
• Physicians and nurses need to accept the notion
  that error is an inevitable accompaniment of the
  human condition, even among conscientious
  professionals with high standards. Errors must be
  accepted as evidence of system flaws, not
  character flaws.
  
• Leape,L. JAMA, 1994

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How can IT support care transformation?

• Error prevention
• Reduced reliance on memory
• Error proofing and constraints (order entry)
• Standardisation/simplification (information and
  process)
• Education, feedback, alerts, decision support
• Potential error detection
• Work-flow, work fulfillment and risk aversion
  programs

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Efficiency with routine chores
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Outpatients all I need
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Inpatients all I need..again!
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• Safety is the single most important by-product of
  automation and CPOE, if done correctly
• Automated ordering cut total errors by 55,
  dosing errors by 23 and allergy errors by 56
• Order changes by clinicians resulting from
  drug-drug or drug-condition notification are
  effective in reducing adverse events
  Bates, D., JAMA, 10-21-98 Raschke, R. , JAMA
  10-21-98
• Many ways to do this incorrectly!
• Start without integration
• Enable mistakes with greater speed and scope
• Create complacency with alert overload
• Allow attention deficits due to overconfidence

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Dose calculation kids, chemotherapy
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Errors are avoidable
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Errors are avoidable
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Errors are avoidable
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Elements of the Transformation model

• Workflow Optimisation
• Transition Management
• Advanced Technology
• Knowledge Management Content
• Software Solutions
• Managed carefully through the cultural change

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Transformation Model
Transformation Process
Before Transformation
After Transformation
Health Care Strategy
Automated Knowledge-Driven Care and clinical
decision support Elimination of waste, errors
and unnecessary variation On-line just in time
contextual references Integrated digital
workflow and data collection High capacity for
information collection, analysis/knowledge
discovery Automated error and adversity checking
Memory - based Care Measurable evidence of
avoidable waste, errors and variation Paper-base
d References Paper-based Documentation Minimal
data collected No capacity for automated
analysis or reporting No automated error or
adversity checking
Advanced Technology
Knowledge, Measurement Content
Software Solutions
Transition Management
Workflow Optimization
Program Management
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Without Unified Architecture Chaos

• Disparate systems disparate care
• Not unified not person-centric

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Architecture Models

• Visual integration
• Inefficient to deploy, manage, maintain
• Difficult, time-consuming to grow or expand
• Risk of major disruption with every minor change
• Person-centric architecture
• Flexible, modular, scalable
• Efficient expansion to devices
• Modifications without disruption

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Culture eats strategy for lunch, every day.
But
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Strategy for Care Transformation

• Is essential to becoming a learning organization
  and to overall transformation
• BUT new information systems in healthcare
• stimulate a specific set of fears in a very
  powerful ancient culture

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Cultural barriers

• Infobia
• Fear of appearing incompetent using technology
• Fear of the effects information will have on
  autonomy, prestige, and organisation position
• Archetypal medical tradition

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Clinicians

• A stern belief in professional autonomy and
  opinion based methods rather than in validated
  knowledge
• A view of guidelines as constraints, implying
  restriction of independent judgment
• Emphasis on recollection, intuition and
  uniqueness
• The belief that repetition establishes validity
• The idea that relationships are authoritarian,
  not cooperative
• Anxiety over the potential ramifications of
  revealing the actual results of interventions
• expectation of perfectionism

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Clinicians fear IT initiatives will

• Waste their time
• Cost them money
• Interfere with their autonomy
• Interrupt their work or thought processes
• Make them change

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Clinicians fear IT initiatives will

• Clinicians are not having trouble dealing with
  change
• they are having trouble dealing with new
  practices that destroy beliefs, defy emotionally
  ingrained learning, threaten personal integrity
  and expertise, endanger social status, imperil
  financial stability, and jeopardize independence
  and personal security.
• Jerry Harvey, How Come Every Time I get Stabbed
  in the Back My Fingerprints on the Knife?
• Understanding and sharing this threat is the
  critical step in managing the transition

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Keys to success with clinicians

• Develop clinical leaders and create cultural
  shift
• Assure adequate executive support for change
• Educate clinicians about benefits
• Define and manage goals and expectations
• Manage incentives and involve clinical leaders

• Train and support with sensitivity to the culture
• Choose systems that meet clinical workflow needs,
  without ignoring organization information
  imperatives
• Leverage immediate benefits for clinicians
• Manage change and resistance at every step
• Berkowitz, L. in, Carter, J. Electronic Medical
  Records, 2001

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Lessons from History

• Computers in the future may weigh no more than
  1.5 tons.
• Popular Mechanics, forecasting the relentless
  march of science, 1949.
• I think there is a world market for maybe five
  computers.
• Thomas Watson, Chairman of IBM, 1943.
• But what...is it good for?
• Engineer at the Advanced Computing Systems
  Division of IBM, 1968, commenting on the
  microchip.
• There is no reason anyone would want a computer
  in their home. Ken Olson, President, Chairman
  and founder of Digital Equipment Corp, 1977.
• This telephone has too many shortcomings to be
  seriously considered as a means of communication.
  The device is inherently of no value to us.
  Western Union internal memo, 1876.

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Dr. Simon Wallace swallace_at_cerner.com