1. HEALTH CARE IS AN INFORMATION MANAGEMENT BUSINESS
PART 1-HEALTH AS AN INFORMATION MANAGEMENT BUSINESS
HOW ARE WE PERFORMING?
AN INTERNATIONAL INFORMATION MANAGEMENT SUCCESS STORY
WHAT ARE THE LESSONS FOR US?
Clinical Associate Professor T. Hannan
FRACP;FACHI;FACMI
St Vincent’s Hospital Sydney, 24th April 2015

2. HEALTH CARE IS AN INFORMATION MANAGEMENT BUSINESS
Clinical Associate Professor T. Hannan
FRACP;FACHI;FACMI
St Vincent’s Hospital Sydney, 24th April 2015

3. HEALTH CARE IS UNAFFORDABLE! [NEJM 2012]-WORLDWIDE
Health Expenditures as a Percentage of Gross Domestic Product (GDP) in Selected OECD Countries, 1960–2009.
AUSTRALIA
Figure 2. Health Expenditures as a Percentage of Gross Domestic Product (GDP) in Selected OECD Countries, 1960–2009. Data for all OECD countries appear in the Supplementary Appendix.
Fineberg HV. N Engl J Med 2012;366:

4. Health care is a service business
What clinicians deliver…
advice
medication
devices
surgery
physical therapy
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5. Health care is an information business
6 November 2018

6. Health care is an information business
What clinicians actually do…
find information (prior records)
gather information (history, physical, lab)
record information (notes, reports, etc.)
process information (risks/benefits → decisions)
transmit information (advice, orders, letters)
The quality, efficiency, and effectiveness of care depend on our ability to manage information
“There is no healthcare without management, and there is no management without information.”
Gonzalo Vecina Neto
Head, Brazilian National Health
Regulatory Agency
→ Electronic Health Records
6 November 2018

7. DATA/INFORMATION/KNOWLEDGE
TSUNAMI
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8. 6 November 2018

9. THREATS TO QUALITY OF CARE
OVERUSE-receiving treatment of no value
UNDERUSE –failing to receive needed treatment
MISUSE-errors and defects in treatment
L. Leape. Five Years After To Err Is Human. What Have We Learned? JAMA. 2005;293:
6 November 2018

10. The law of diminishing returns.
MGH's Inpatient Mortality Rate (Brown) and Adjusted Cost per Patient Who Was Discharged Alive (in 2010 MGH's Inpatient Mortality Rate (Brown) and Adjusted Cost per Patient Who Was Discharged Alive (in 2010 Dollars; Blue), 1821–2010.
Dollars; Blue), 1821–2010.
The law of diminishing returns.
MGH's Inpatient Mortality Rate (Brown) and Adjusted Cost per Patient Who Was Discharged Alive (in 2010 Dollars; Blue), 1821–2010.
Seems to be characterized by diminishing returns, with growth in costs far outpacing reductions in inpatient mortality. Treatment of severely ill patients with increasingly complex conditions contributes to this phenomenon, but that fact does little to mitigate the reality that for the first time, improvements in inpatient mortality may be coming at unsustainable increases in cost. Close examination of our past clarifies just how daunting is the challenge we face today
Two Hundred Years of Hospital Costs and Mortality — MGH and Four Eras of Value in Medicine
Gregg S. Meyer, M.D., Akinluwa A. Demehin, M.P.H., Xiu Liu, M.S., and Duncan Neuhauser, Ph.D. N Engl J Med 2012; 366:

11. Poorly or Unsupported Clinical Decision Making RESOURCE UTILISATION-CANADA OVERUSE-5% CKD patients 25% Duplicate testing
~$4.55 M (~$4.50/test)
Dr. Adeera Levin, Director, Kidney Function Clinic, St. Paul's Hospital, University of British Columbia, Rm A, 1081 Burrard St., Vancouver BC V6Z 1Y6; fax ; 11

12. OVERUSE / INAPPROPRIATE USE OF RADIOLOGY / PHARMACY RESOURCES
CANADA
Prescriptions-community pharmacies-
272 million (1999) to 483 million (2009).
Appropriate vs. Inappropriate use?
CT scanners -198 to 465
MRI scanners- 19 to 266 from federal investments.
Number of Scans:
58% increase CT scans
100% increase MRIs. (Compared to 2003)
Source:
Heather Dawson Director, Analysis and Reporting, Health Council of Canada Healthcare Policy Vol.6 No.4, 2011
6 November 2018

13. RESOURCE UTILISATION- DEM AFTER HOURS
UNITED KINGDOM:
RESOURCE UTILISATION- DEM AFTER HOURS
Resource Utilisation /99
87% Unnecessary out-of-hours tests
80% Diagnostic uncertainty
79% Medico-legal protection *
66% Avoid leaving work for colleagues
71% Prevent criticism from staff (especially Consultants)
76% Lessen anxiety and reduce stress levels
71% Agreed attempts should be made to reduce unnecessary testing
McConnell AA, Bowie P. Health Bull (Edinb) Jan;60(1):40-3.
Unnecessary out-of-hours biochemistry investigations--a subjective view of necessity.
6 November 2018

14. PRACTISING UNDER THE FEAR OF LITIGATION
Without individualized data, physicians assume that they are performing at tolerable rates.
2000 Project HOPE—People-to-People Health Foundation, Inc. Health Affairs, March/April 2000 Medicare Pharmacy Coverage: Ensuring Safety Before Funding by Lee N. Newcomer
Is More Testing Better?
The “diagnosis of uncertainty”-effects on clinical decision-making behaviour, costs and outcomes.
(Takes CDM further away from the Dx)
1. N Engl J Med Jul 31;293(5): Therapeutic decision making: a cost-benefit analysis. Pauker SG, Kassirer JP.
2. Johns RJ, Blum BI. The use of clinical information systems to control cost as well as to improve care. Trans Am Clin Climatol Assoc. 1979;90:
6 November 2018

15. 1994-2007 Direct communication Hosp-PCP 3-20%
COMMUNICATION-HOSPITALS TO PRIMARY CARE- Kriplani:JAMA 2007
Direct communication Hosp-PCP 3-20%
Availability of Discharge Summary
1st post discharge visit-12-34%
4 weeks-51-77%
Affect on QOC of FU visits-25%
PCP dissatisfaction HIGH
Communication lacking important information
Diagnostic test results missing
33-63%
Treatment or hospital course
7-22%
Discharge medications
20-40%
Test results pending at discharge
65%
Patient or family counselling
90-92%
Follow-up plans
2-43%
6 November 2018

16. ADVERSE EVENTS -IDENTIFICATION AND PREVENTION
2006 Institute of Medicine -nearly 1.5 million preventable adverse drug events each year.
Hasan, S., G. T. Duncan, et al. "Automatic detection of omissions in medication lists." J Am Med Inform Assoc 18(4):
“Most hospitals rely on spontaneous voluntary reporting to identify adverse events, but this method overlooks more than 90% of adverse events detected by other methods Retrospective chart review improves the rate of adverse event detection but is expensive and does not facilitate prevention.”
Potential identifiability and preventability of adverse events using information systems. D Bates et.al J Am Med Informatics Assoc. 1994;1:
Conclusions drawn from a similar study to the previous slide by Bates from Brigham's & Women's Hospital in Boston. It is self-explanatory and confirms the inadequacy of the paper chart and its ability to support clinical decision making and is costly.
6 November 2018

17. Medication-related malpractice claims
ADE - 6.3% of claims Preventable 73%
IP vs. OP = 50% 46% -life threatening or fatal.
ADE and malpractice claims
severe, costly, and preventable.
Rothschild JM, Federico FA, Gandhi TK, Kaushal R, Williams DH, Bates DW. Analysis of medication-related malpractice claims: causes, preventability, and costs. Arch Intern Med Nov 25;162(21):
6 November 2018

18. SLOW LEARNERS-ON QUALITY AND PATIENT SAFETY
2000-To Err Is Human Building a Safer Health System. INSTITUTE OF MEDICINE.
2005 -Leape, L.L. and D.M. Berwick, Five years after To Err Is Human: what have we learned? JAMA.
2011- Health Information Technology Institute Of Medicine, Health IT and Patient Safety Building Safer
Systems for Better Care, The National Academies
Press: Washington D.C.
2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer
care. N Engl J Med.
6 November 2018

19. Time to tackle unwarranted variations in practice
THE VARIATION PHENOMENON “The variation phenomenon in modern medicine -the observation of differences in the way apparently similar patients are treated from one health care setting to another.” D. Blumenthal. Editorial NEJM 331:1994; Much of the variation in use of healthcare is accounted for by the willingness and ability of doctors to offer treatment rather than differences in illness or patient preference. Variation that cannot be explained on the basis of illness, patient preferences or the dictates of evidence-based medicine. [APPROPRIATE AND INAPPROPRIATE VARIATION-Brent James] Identifying and reducing such variation should be a priority for providers. (John Wennberg 2011-Dartmouth Institute)

20. Reasons for practice variation
Complexity:
How many factors can the human mind simultaneously balance to optimize an outcome?
Lack of valid and poor access to clinical knowledge -(poor evidence)
Subjective judgment / uncertainty
Subjective evaluation is notoriously poor across groups or over time and enthusiasm for unproven methods
Brent James summary of the the reasons for practice variation. All these factors involve complex decision making in an information rich environment.
Human error- -- humans are inherently fallible information processors- -- Clem MacDonald, PhD

21. Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrolees in higher-spending regions.
The Implications of Regional Variations in Medicare Spending. Part 1:The Content, Quality, and Accessibility of Care Elliott S. Fisher, MD, MPH; Ann Intern Med. 2003;138:
6 November 2018

22. Does more $ per capita improve care?

23. Technology is NOT the problem. RMRS 2012 (est. 1976)
Regenstrief Institute: April 2012: 18 hospitals
>32 million physician orders entered by CPOE
Data base of 6 million patients
900 million on-line coded results
20 million reports-diagnostic studies, procedure results, operative notes and discharge summaries
65 million radiology images
CLINICAL DECISION SUPPORT- BLINK TIMES (CCDSS-through iterative Dbase analysis)
In a 1999 review of the major EMR systems in the world that are the models for future EMRs, these were the data/information and performance values for the Regenstrief system in Indian. They emphasize that technology is not the problem for EMRs and information retrieval must function at these levels of recall time.
6 November 2018

24. CCDSS IMPROVING RESOURCE UTILISATION, OUTCOMES
$3 million per year savings ~$64bUS(1995) (? 2013-$tr)
Tierney’s study into the use of of a longitudinal CBPR to reduce resource utilization. (Refer to the Johns and Blum study on costs, resource utilization, and clinical decision making)
Physician inpatient order writing on microcomputer workstations-effects on resource utilisation. WM Tierney and others. JAMA 1993;269:
6 November 2018

25. COSTS/QUALITY/OUTCOMES/RESEARCH “The plural of anecdote is not data”
CCDSS(EHR) 1996
COSTS/QUALITY/OUTCOMES/RESEARCH
“The plural of anecdote is not data”
160,000 patient over 4 years
Overall antibiotic use: decreased 22.8%
Mortality rates: decreased from 3.65% to 2.65%
Antibiotic-associated ADE: decreased 30%
Antibiotic resistance: remained STABLE
Appropriately timed preoperative a/biotics: 40% to 99.1%
Antibiotic costs per treated patient: decreased $ to $51.90
Acquisition costs for antibiotics: fell 24.8% to 12.9%
($987,547) to ($612,500)
Our Case-Mix index which measures patient acuity levels INCREASED during this period, meaning we were treating sicker and sicker patients while better utilizing the delivery of antibiotics. (******WENNBERG 2012)
Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15
6 November 2018

26. PricewaterhouseCoopers LLP (PwC) switch to electronic medical records (EMR) by family doctors from across Canada between 2006 and 2012
$800 million
$584 million
6 November 2018

27. “Clayton, the Internet is a corner I will not turn
“Clayton, the Internet is a corner I will not turn.” “There is no mail here!” “What’s a scroll bar?” Permissions: Clayton Lewis, Professor of Computer Science, University of Colorado NAS. Fostering Independence, Participation, and Healthy Aging Through Technology: Workshop Summary Gregg Vanderheiden, Director Trace R&D Center, Professor Industrial & Systems Engineering and Biomedical Engineering University of Wisconsin-Madison

28. 2,500+ s later
Permissions: Clayton Lewis, Professor of Computer Science, University of Colorado NAS. Fostering Independence, Participation, and Healthy Aging Through Technology: Workshop Summary Gregg Vanderheiden, Director Trace R&D Center, Professor Industrial & Systems Engineering and Biomedical Engineering University of Wisconsin-Madison

29. A SUCCESSFUL INTERNATIONAL
MAKING IT WORK
A SUCCESSFUL INTERNATIONAL
CLINICAL INFORMATION
MANAGEMENT PROJECT
FROM KENYA TO THE WORLD
"Talkin' about a revolution“ Braitstein 2009

31. Global AIDS in How Big?
Leading infectious cause of adult death in the world
Leading cause of death in adults aged 15–59
40 million persons now living with HIV/AIDS, 50% women
>70% of HIV-infected persons living in Africa
14,000 new infections daily
Sexual transmission responsible for more than 85% of infections
6 million in need of immediate treatment
Fewer than 8% receiving it
SOURCES: Quinn and Chaisson, 2004; WHO, 2003a,b.

32. AIDS in Kenya-2000 2.5 million persons infected (15% of adults)
4th behind South Africa, India, and Nigeria
1 million AIDS orphans (of 31 million citizens)
Life expectancy has dropped 18 years in the past 5 years, from 65 → 47 years

33. Face of HIV in Africa
OpenMRS was created in response to HIV/AIDS. Indiana University School of Medicine had been collaborating with Moi University Faculty of Health Sciences (Eldoret, Kenya) for over a decade when their focus, by necessity, turned toward the HIV pandemic.
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34. One solution: Academic collaboration [Africa cannot do it alone]
14-year collaboration between IU and MU
1st 11 years → focus= educational exchange
In 2000-pre EMR
>50% of the beds in Moi Hospital were filled with young people dying of AIDS
no ARVs, few antibiotics for opportunistic infections
despair, depression, resignation
Then…Daniel

35. Daniel……on treatment What Daniel was like preRx [this in not Daniel]
4th Year Medical Student

36. Clinical Information Management-
the report that changed HIV/AIDS in Africa!
Use of OpenMRS (MMRS was precursor) allowed us to manage care in a timely manner

37. Clinical Information Management-
the report that changed HIV/AIDS in Africa!
Collecting this clinical information allowed effective measurement of the AIDS epidemic and therefore the ability to manage it in the future.
Use of OpenMRS (MMRS was precursor) allowed us to manage care in a timely manner

38. Clinical Information Management-
the report that changed HIV/AIDS in Africa!
Collecting this clinical information allowed effective measurement of the AIDS epidemic and therefore the ability to manage it in the future.
Use of OpenMRS (MMRS was precursor) allowed us to manage care in a timely manner
WHAT IS MISSING?

39. HIV and TB = 0 Not measured!
Clinical Information Management-
the report that changed HIV/AIDS in Africa!
HIV and TB = 0
Not measured!
Collecting this clinical information allowed effective measurement of the AIDS epidemic and therefore the ability to manage it in the future.
Use of OpenMRS (MMRS precursor) allowed us to manage care in a timely manner

40. END USER INVOLVEMENT CRITICAL TO SUCCESS-
INNOVATION-EARLY MOBILE TECHNOLOGIES
An innovative home-care program using hand-held computers being piloted in the region. Monica Korir, who is living with HIV and is trained as an outreach worker
Outreach workers download completed forms into Mosoriot clinic's data management system daily. Automated alerts flag any alarming new symptoms/missed appointments/medication compliance.
WHO/Evelyn Hockstein
6 November 2018

41. Early Patient Held (Health) Records Education/Self management/Access
6 November 2018

42. Musafa
But patients like Musa, who you’ve already met, showed that HIV was a treatable disease. The problem wasn’t how to treat HIV, but how to scale that up to 100,000 and millions of patients. That kind of scale could only be obtained through effective information management.
HIV is a treatable disease, but treating millions requires information management.
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43. Measuring Care-the impacts Individuals/Social/Economic
Effective clinical information management using OpenMRS
The Present…
The Past…
The Impact…
Clinical information management

44. ALL DISEASE STATES NOT JUST HIV/AIDS
AMPATH [Academic Model Providing Access to Healthcare] clinical and support programs capturing electronic data.
ALL DISEASE STATES NOT JUST HIV/AIDS
Adult HIV/AIDS clinics
Pediatric HIV/AIDS clinics
Primary care – rural health
clinics
Primary care – urban well-child
Antenatal and postnatal clinics
Mother-baby register
Oncology clinics
Mental health clinics
Diabetes clinics
Tuberculosis clinics
Clinic pharmacies
Clinical laboratories
Social worker assessments
Outreach – patient follow-up
Drug adherence assessments
Nutrition assessments
Food supplement distribution
Microfinance program
AMPATH maintenance cost only $175/patient/year in 2007 and is now less than $100/patient/year in 2009
[dividing all direct USAID/PEPFAR funding per year by the number of patients actively receiving treatment.] 
6 November 2018

45. Collaborators and Funders for OpenMRS
Partners In Health
Regenstrief institute
Medical Research Council, South Africa
World Health Organization
US Centers for Disease Control
Brigham and Women hospital
Harvard Medical School
University of KwaZulu-Natal
Millennium Villages Project
International Development Research Centre, Ottawa
Rockefeller Foundation
Fogarty International Center, NIH
Boston Consulting Group
Google Inc
PEPFAR
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46. DEVELOPER TRAINING – RWANDA

47. DATA CAPTURE IN AMPATH Patients Enrolled by Month: Nov ’01 – Jan ‘12
Patient Visits By Month: Nov ’01 – Jan ‘12
Cumulative Patients Enrolled: Nov ’01 – Jan ‘12
Cumulative Patient Visits: Nov ’01 – Jan ‘12
DATA CAPTURE IN AMPATH

48. IT’S ALL ABOUT THE DATA AMRS Observations By Month: Mar ’06 – Jan ‘12
Cumulative AMRS Observations By Month: Mar ’06 – Jan ‘12

49. MTCT-Plus
Program
AIDS
Clinical
Trials
Group
GN for
Women’s &
Children’s
Health
Research
NHLBI
Global Health
Initiative
IeDEA

50. DESIGN GOALS FOR COMPLEX E-HEALTH SYSTEMS[Taken from OpenMRS]
COLLABORATION:
SCALABILITY / SUSTAINABILITY:
FLEXIBILITY:
RAPID FORM DESIGN:
USE OF STANDARDS:
SUPPORT HIGH QUALITY RESEARCH:
WEB-BASED AND SUPPORT INTERMITTENT CONNECTIVITY:
LOW COST: preferably free/open source
CLINICALLY USEFUL: feedback to providers and caregivers is critical. If the system is NOT CLINICALLY USEFUL it will not be used.
AMPATH Medical Record System (AMRS): Collaborating Toward An EMR for Developing Countries Burke W. Mamlin, M.D. and Paul G. Biondich, M.D., M.S. Regenstrief Institute, Inc. and Indiana University School of Medicine, Indianapolis, IN

51. EVALUATION IS CRITICAL
"Talkin' about a revolution":2009
“Now HIV/AIDS programs are not only in place but some of them, ……(partnerships)…..(AMPATH) …are openly speaking of bringing the pandemic to its knees over the next 5 years through widespread screening and effective treatment and prevention of HIV [and other diseases] .”
Braitstein, P., et al., "Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings. J Acquir Immune Defic Syndr, Suppl 1: p. S54-7.
6 November 2018

52. (68% intervention vs 18% control, P , .001).
Computer-Generated Reminders and Quality of Paediatric HIV Care in a Resource-Limited Setting
4 x increase in the completion of overdue clinical tasks with reminders
(68% intervention vs 18% control, P , .001).
Orders occurred earlier for the intervention group (77 days, SD 2.4 days)
control group (104 days, SD 1.2 days) (P , .001)
Response rates to reminders varied significantly by type of reminder
and between clinicians.
Martin C. Were, MD, MS, Winstone M.Nyandiko, MBChB, MMED, MPH,c,d Kristin T.L. Huang, MD,James E. Slaven, MS,f Changyu Shen, PhD,f William M.Tierney, MD,Rachel C. Vreeman, MD, MSb Pediatrics 2013;131:789–796 C. Vreeman, MD, MSb Pediatrics 2013;131:789–796
6 November 2018

53. Predecessors of OpenMRS
The Mosoriot Medical Record
MS Access based EMR developed at AMPATH in Kenya in 2000
Supported primary care and later HIV care

54. Predecessors of OpenMRS
The PIH-EMR
Web based EMR system developed for MDR-TB and then HIV care in
Deployed in Peru, Haiti and Rwanda

55. OpenMRS: a modular, open source, EMR platform

56. SCALABILITY May 2012
6 November 2018

57. Also clinicians are slow to change-the “culture of medicine”
“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”
Dr. Lucian Leape -Harvard School of Public Health-2009
Also clinicians are slow to change-the “culture of medicine”
Five Years After To Err Is Human. L. Leape. What Have We Learned? JAMA. 2005;293:

58. Data capture and management is critical to measuring health care
“We must remove ourselves from the ‘unscientific, non data driven personal recommendations’ for care”. Dr. M. Smith CHCF AMIA 2009
“The ability to feedback immediately to the people at the point of care is critical for measuring and improving the quality of care.
A/Prof Andy Kanter April, Millennium Villages Project

59. Oh no!
Where to from here?