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Healthcare Informatics Society of Ireland16th Annual Conference and Scientific Symposium
Improving Quality and Reducing Cost in Health CareThe role of information and information technology
16 – 17 November 2011
Professor Matthew Swindells
Chair of the British Computer Society, HealthSenior Vice President Global Consulting, Cerner Limited
Visiting Professor, Surrey University School of Health Management
Confront the received wisdom
Access Times
Cost
Quality Failures
reduction
increase increase
Access Times
Cost
Quality Failures
reduction
reduce reduce
Through the application of information and technology:Reduce costImprove accessImprove quality
Budget pressures everywhere ... CANADA: From 2012–13 to 2017–18, the
Ontario government will attempt to hold
health-care spending increases to just 3 per
cent per year. Over the last five years, health-
care spending has risen by an annual average
of 6.5 per cent. (March 2010)German Health Care Spending Cut, Fees
Raised (July 2010)
DANISH healthcare spending cuts (June 2010)
ITALY: EUR24bn
Austerity Package
Contains Healthcare
Spending Cuts (June
2010)
SPAIN’s budget for healthcare has been
decreased by 2.8 billion euros through a 19
billion dollar austerity plan. (WHO, June
2010)
IRELAND: THE HEALTH budget will be cut by €1.4 billion between now and 2014 under the National Recovery Plan. (Nov 2010)
ENGLAND: The NHS is
expected to make savings of
between £15- £20bn over the
next 3 years. (Sept 2009)
Not just …
The cost of technology
The cost implications of ageing
Dutch study• A 90 year old consumes 10x as much healthcare as a 50 year old• Cost increases over just 4 years is much greater, the older the age group
UK Implications• Ageing population• Very elderly group growing the fastest• 75+ costs 5x as much per annum as a 40 year old
How to drive cost reduction
Make the institutions more productive Make the system more productive
Start by exposing data through portals
Rural Hospital ClinicLocal Hospital
Satellite Campus
Pharmacy
Rehab
Surgery
ImagingCenter
Nursing Home
Government
Physician Office
Laboratory
Healthcare System/Hospital(main campus)
Then join up the parts of the system
Then drive process efficiency
Schedule nurse time effectively
Automate infusion management
Integrated, actionable information availability
Managing discharges to reduce readmissions
Reducing cost through the use of evidence
We know there is a great deal of variation
0
10
20
30
40
50
60
6 fold variance of your chances of surviving an aneurism across London
4 fold variance of your chances of surviving a stroke across London
0
5
10
15
20
25
30
3510 fold variance of your chances of surviving a heart attack across London
Despite 15 years of evidence based standardisation there is still wide variation in outcomes across the NHS
Data 2005/06
Outcome against cost of intensive care
No evidence that shows that spending more creates better outcomes or spending less creates worse
Data 2005/06
How to address this - the use of evidence
Arch Intern Med 1998;158:1665-8Lancet 1995; 346:407-10
Strong evidence
(RCTs) 57%
Practice Based Evidence
27%
No substantial evidence
16%
(n=150 patients)
Evidence-Base for Pneumonia
Major therapeutic decision Not a major therapeutic decision
Selection of antibiotic FBC on day 3
(courtesy Jeff Rose MD, Ascension Health)
Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting
12-month cumulative cost by Pathway status.
Neubauer M A et al. JOP 2010;6:12-18
©2010 by American Society of Clinical Oncology
Slow Innovation AdoptionFrom time new knowledge discovered until ½ of physicians act on that knowledge = 15 - 17 years
Everett Rogers, Diffusion of Innovations, 1995
% o
f popu
lati
on
time
Adoption Half-life = 17y
Knowledge Half-life = 10y
Balas, Boren. Managing Clinical Knowledge for Health Care Improvement.
Yearbook of Medical Informatics 2000
“Finish medical school and residency knowing
everything…read and retain 2 articles every
single night…at the end of 1 year you’re only 1,225
years behind.”W Stead. JAMIA 2005;12:113-20
Alper BS, Hand JA, Elliott SG, et al. J Med Lib Assoc 2004;92:429-37
The cost of memory based care The adverse drug reactions,
which account for some 3% to 5% of all hospital admissions in the UK, cost the NHS in the order of £500 million per year *
Hospital errors resulting in preventable adverse drug events occurred most often:
* Health Select Committee Report, The Influence of the Pharmaceutical Industry, 2005** Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug
events. Implications for prevention.1995
Closed loop medication management
34%4% 56%
**
VitalsLab
Rad
Electronic Documentation
OrderManagement
PharmacyManagement
Electronic Medication
Administration
In Spain each adverse drug reactions, which account 3.47% of big hospital admissions , cost around 3,200€.
Technology Enabled Clinical Decision Support
Predictors of Success Adjusted OR
Automatic provision of decision support as part of workflow
112.1
Provision of decision support at the time and location of decision making
15.4
Provision of recommendation rather than just an assessment
7.1
Computer-based generation of decision support
6.3
Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005 Apr 2;330(7494):765. PMID: 15767266
75% of decision support interventions succeed when the information is provided to clinicians automatically, whereas none succeed when clinicians are required to seek out the advice
HCIT evaluation of 167,233 patients at 41 hospitals
Clinical decision support associated with:
– 21% mortality reduction for pneumonia
– 16% reduction in patient complications
Electronic Process Cost Savings Per Patient
Decision support $538
Order entry $132
Test results $110
Notes and records –$2
Potential US Implications:$19 billion savings per year10,055 lives saved for patients with CAP25,141 patient complications avoided
Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009 Jan 26;169(2):108-14. PMID: 19171805
Improve care with technology
Support decisions with rules and alerts
Guide clinical practice with executable knowledge
Collect data as part of the care process
Imbed real clinical evidence - Sepsis
Existing Patient in Acute Care
Setting At least 1 sign of organ dysfunction
+ 2/5 SIRS
2/5 SIRS Criteria
Met?
Temp: <36 or >38.3 C
Sepsis Screening Rule
SIRS Alert-Suggests labs/
cultures not found on
database to clinician
Plasma Glucose >120
WBC: >12k, <4k, or >10%
Bands
· Discern Notify-· RN· Physician· RRT-Pager
Colony stimulating
factors within last 60 days?
Diagnosis of Diabetes?
Exclude from SIRS
Criteria
Yes
Yes
Heparin order within last 24
hrs?
Exclude PTT from organ dysfunction
criteria
Yes
Creatinine the only elevated
lab?
Yes
No
Diagnosis of ESRD?
No
Patient taking recombinant
human erythropoietins
Yes
Continue Monitoring
No
Fire Sepsis Alert / Send Notifications
DTA’s Used for SIRS Criteria:TemperatureHeart RateRespiratory RateGlucose LvlBlood Glucose, CapillaryWBCBand Man
DTA’s Used for Organ Dysfunction:Lactic Acid LvlSystolic Blood PressureMean Arterial PressureCreatinine LevelBili TotalPlatelet CountNeurological SymptomsLevel of ConsciousnessHallucinations Present Affect/Behavior Glasgow Coma ScorePediatric Coma Score PTTPaO2/FiO2 ratio
Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 Intensive Care Med (2008) 34:17–60DOI 10.1007/s00134-007-0934-2International Sepsis Definitions Conference. Crit Care Med 2003; 31:1250 –1256. ACCP/SCCM Consensus Conference Committee: American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in
sepsis. Crit Care Med 1992; 20:864–874
No
Labs to be suggested to clinician if not found on database within timeframe:Lactic Acid LvlCreatinine LevelBili TotalPlatelet CountPTTBlood CulturesUA
No
Yes
Lactate >2.0 mmol/L
SBP <90 or MAP <65mmHg
SBP decrease >40mmHg from previous reading
Bilirubin >2.0mg/dl
Mental Status Change
PaO2/FIO2 ratio <300
aPTT >60 seconds
Platelet Count <100,000
Creatinine >2.0 gm/dl
Continue Monitoring
Yes
No
· Discern Notify-· RN
Look back 48 hours for organ
dysfunctionRR: >22
HR: >95
Continue Monitoring
Yes
Engaging the patient in managing their own health
Engaging the patient in managing their own health
DavidYour blood pressure is a little high. A nurse will call you today.