andrew georgiou, australian institute of health innovation - improving health information and data...
TRANSCRIPT
Centre for Health Systems and Safety
Research
Improving Health Information and
Data Management – the Evidence
of e-Health’s Impact
Associate Professor Andrew Georgiou
Senior Research Fellow
Outline • Background
o Existing evidence of the impact of
health Information Technology
• Aim and Method
o Key performance indicators of
laboratory performance
• Results
o The impact on efficiency,
effectiveness and patient
outcomes and safety?
o The challenge of safe test result
follow-up
• Conclusion
Evidence of the impact of health
information technology
• 257 studies (24% from 4 US centres, all
home grown systems)*
• Only 4% (n=9) studies examined the
impact of commercial systems
• 8** years later - increase in number and
scope of studies (13% per year <2007,
25% >2007)
• 56% report uniformly positive results,
21% mixed-positive effects
• Poor reporting of context and
implementation details
*Chaudhry et al (2006) Ann Intern Med ** Jones et al (2014) Ann Intern Med.
Evidence of the impact of health IT
• Most lab studies showed
decreases in ordering
including a 27% reduction in
redundant lab tests
• Most lab and imaging
studies showed improved
adherence to guidelines and
improved efficiency (up to
50% for labs)
• Few studies across multiple
sites
• Lack of outcome measures
The aged care informatics
challenge
• A fragmented service
• The delivery of “seamless” care
• Integration of services
• ICT “laggard”
• Lack of solid research evidence of
the contextual and holistic
functioning and requirements of
aged care
How aged care staff spend their
time? • A median of six forms completed each
day per staff member
• 69% of staff spend time transferring information from paper to computer (30 mins/shift)
• Median of 3.5 faxes and 3.5 phones calls to GPs/pharmacy per day
• 35.4% reported that they always had access to residents’ hospital information after discharge
Gaskin et al. BMC Geriatrics (2012)
Research question
What is the impact of the
Electronic Medical Record
on pathology services, their
work processes and
relationships with other
departments, and on key
performance indicators?
Key performance metrics
Georgiou et al. Int J Med Info 2006
Test orderTest
processing
Test result
application
Costs Work practices
Test volumesRedundant test
rates
Guideline compliance
Turnaroundtimes
Doctor-lab communication
Patient management
Length of stay
Patient safety
Average turnaround time in minutes
Before implementation
(95% CI)
After implementation
(95% CI)
t test results*
All test assays 73.8 (72.2-95.4)
58.3 (57.1-59.4)
t=15.6 (df 184257)
p=0.000
Prioritised tests 44.6 (42.4-46.8)
40.1 (38.7-41.6)
t=3.3 (df 37830)
p=0.001
Non-prioritised
tests 81.5 (79.6-83.5)
65.9 (64.4-67.4)
t=12.6 (df 148493)
p=0.000
Tests in business
hours 81.8 (80.1-83.5)
69.0 (67.4-70.6)
t=10.7 (df 141219)
p=0.000
Tests outside
business hours 54.0 (50.6-57.4)
39.2 (37.8-40.5)
t=7.9 (df 37524)
p=0.000
Tests in control
ward 68.7 (63.9-73.5)
64.7 (60.4-69.0)
t=1.2 (df 12993)
p=0.218
Westbrook et al. (2006) J Clin Pathol
TAT pre & post EMR in four
hospitals
2005
Before 2006
After 2007
After Kruskal-Wallis
Hospital A - Median TAT 77 68 66 P<0.001
% tests using EMR 75% 80%
Hospital B - Median TAT 145 129 108 P<0.001
% tests using EMR 0-44% 57%
Hospital C- Median TAT 138 135 113 P<0.001
% tests using EMR 29-38% 53%
Hospital D- Median TAT 141 139 128 P<0.001
% tests using EMR 56-71% 74%
Median TAT in minutes
Volume of tests and
specimens* Average number of test assays per
patient did not change
92.5 assays/patient versus 103.2
(P=0.23)
Average number of specimens per patient
did not change
10.8/patient versus 11.7 (P=0.32)
*Westbrook et al. (2006) J Clin Pathol
Cumulative percentages of repeat testing, as a proportion of all tests ordered, within one-hour to 35-
hours of the previous test, for tests orders using the paper-based (dashed line) and electronic ordering
system (solid line).
Quality of pathology
ordering
Specification of
gentamycin specimens
Before 16% of gentamicin and 13% of vancomycin samples specified as peak or trough.
After significant increase - 73% for gentamicin and 77% for
vancomycin.
Westbrook et al. J Clin Pathol 2006
The impact of electronic ordering
on information exchange
Wound specimens with a request
specifying source and body site
Before electronic ordering (2005) 578 (69.6%)
One year later (2006) 774 (92.9%)
Two years later (2007) 814 (95.3%)
Three years later (2008) 877 (95.6%)
Incident Information Management System
(IIMS) reported errors
EMR Paper
Mislabelled specimen 0.1
(n=39)
0.31
(n=56) p<.001
Mismatched specimen 0.49
(n=200)
1.42
(n=255) p<.001
Unlabelled specimen 1.37
(n=559)
1.65
(n=296) p<.01
Missed test results
• Critical safety issue – increases
the risk of missed or delayed
diagnoses World Alliance for Patient Safety, WHO, 2008; Schiff, 2006
• Clinicians are concerned that their
test management practices are
not systematic Poon et al. Arch Int Med 2004
• Medico-legal concerns Berlin, AJR, 2009
• Impact on patient outcomes Roy et al. Ann Intern Med, 2005
How many results are missed for
hospital patients?
• Hospital inpatients 20% - 62% of tests are missed
• ED patients (discharged) 1% - 75% of tests are missed
Callen et al. BMJ Qual Saf 2011;20;194-199
• Ambulatory patients 7% - 62% laboratory tests missed
1% - 36% imaging tests missed
Callen et al. Jnl Gen Int Med, 2012
Study methods
Survey design (17 questions)
1 metropolitan ED; senior ED doctors
Significantly abnormal results
– not life threatening but need short-term
follow-up (e.g., chest x-ray with new shadow,
abnormal PSA)
Automatic patient notification methods
– Patient portal, Email, SMS, fax, mail or
phone
What types of tests were missed?
(%)
Are there standard policies and
procedures for patient notification of
results?
Perceptions of missed test results
19.2
26.9
53.9
In the past year I have missed an abnormal result that led to delayed
patient care
Yes (%)
No (%)
Don't know (%)
38.5
11.5
50
In the past year a colleague has missed an abnormal results that led
to delayed patient care
Yes (%)
No (%)
Don't know (%)
• Mater Mothers’ Hospital (Brisbane)
• IP Health Verdi software which allowed
clinicians to electronically document
review and acknowledgement of test
results (2010)
• Hospital data (Aug ’11 – Aug ‘12) involving
27,354 inpatient tests for 6855 patients
• All test results were acknowledged
• 60% of laboratory and 44% of imaging
results acknowledged within 24h
An electronic safety net to enhance test
result management
Safety considerations with health IT
implementation • Solutions need to be multipronged
• Policies, procedures and
responsibilities
• Role of patients, doctors, nurses,
clerical staff and laboratories in
the follow-up process
• Evaluation of information and
communication technology (ICT)
solutions
• Integrate solutions with work
practices of health professionals
Acknowledgements
Australian Research Council (ARC) Linkage Grant (LP0347042) to
evaluate the impact of information and communication
technologies on organisational processes and outcomes: a multi-
disciplinary, multi-method approach (2003 – 2007)
ARC Linkage Grant (LP0989144) to investigate the use of information
and communication technologies to support effective work practice
innovation in the health sector (2008 – 2012)
ARC Discovery Grant (DP120100297) to evaluate an electronic test
management system in health care (2012 – 2014)
Department of Health Quality Use of Pathology Program grant (2008-
2009), (2011-2012)
