1. Medical Engagement and Medication Safety James Williamson Sir Charles Gairdner Hospital

2. Points to ponder Clinician ‘buy-in’: A fragile relationship? Systems medicine: A Brave New World? Changing clinical practice: An uphill battle?

3. Points to ponder Clinician ‘buy-in’: A fragile relationship? Systems medicine: A Brave New World? Changing clinical practice: An uphill battle?

4. Clinician engagement …the manner in which the health service involves people who provide direct patient care in the planning, delivery, improvement and evaluation of health services

5. Very early involvement 147 physicians engaged in product selection 12 specialty specific Physician User Groups (PUGS) 2 advocate physicians on steering group Physicians on Clinical Informatics Group 6 clinicians paid for 2 years broad specialty mix accountable for specific tasks & deliverables “Small investment to guarantee success” Clinician Buy-In: USA (Queens)

6. Year 1996199719981999200020012002 Clinician Involvement PCGs CISGs Quality Funding Task Force Clin Ref Group Clinician Buy-In: WA

7. Year 1996199719981999200020012002 Clinician Involvement Clinician Buy-In: WA

8. Pitfalls in Clinical IT Projects Lack of targets — ‘You get what you ask for’ Lack of boundaries — scope creep Lack of physician champion(s) Poor leadership — look for change leaders Using formal meeting format rather than facilitation Poor communication: failing to manage expectations Inconsistent deadlines Politics over good judgment Not including line staff: not listening to them Not picking your battles Focus on minutiae without context of improvement

9. Medical Engagement Be prepared to answer the following questions: What’s in it for me? What’s in it for my patients? …but not necessarily in that order! Provide time, money, structure, data, and support Use expertise and build capacity for the future

10. What’s in it for my patients? 30,195 random records from 51 NY hospitals 1133 Adverse event (3.8%) 178 Drug-related (ADE; 0.59%) 25 serious (0.08%) [32 negligent] (Leake et al, NEJM 324; 377-384, 1991) ~20% of disabling adverse events were drug-related

11. Pitfalls in Clinical Engagement Multiple mechanisms Senates, Councils, Lead Clinician Groups, Clusters, Networks … No clear (sustained) governance SHEF-ICT Principal Cttee vs FSH CCG Focus on facilities, not systems FSH, NCH, Albany Failure to seek / heed advice Medication management Failure to fund business change All (including training and support) Death by Business Case WAND Over-value consultants ; under-value own staff Secondments build capacity Transient funding Incomplete projects (RA, CPOE); clinical leads lost Unfulfilled expectations All (even if expectations low!)

12. Maintain Focus & Relevance ~50% of medication errors in prescribing phase Reduce harm, not errors high risk drugs, high risk patients Systems, not individuals

13. Risks Insulin Anticoagulants Antibiotics Chemotherapy Polypharmacy Extremes of age Renal impairment Poor communication DrugsPatients Systems

14. Adverse Drug Events on the AAU

15. Risks Insulin Anticoagulants Antibiotics Chemotherapy Polypharmacy Extremes of age Renal impairment Poor communication DrugsPatients Systems

16. Points to ponder Clinician ‘buy-in’: A fragile relationship? Systems medicine: A Brave New World? Changing clinical practice: An uphill battle?

17. Personally-Controlled EHR Birth to death Authorised access Subject to scrutiny Available at PoC Simultaneous access

18. Building Blocks

19. National Electronic Decision Support Task Force “Access to knowledge stored electronically to aid patients, carers and service providers in making decisions on health care” Emphasis on clinical and point of care information

20. Origins of the Task Force (NHIMAC & NICS, Nov 2001)

21. Using clinical knowledge

22. Physician Order Entry Diagnostic tests –proven cost savings –proven benefits in workflow (order sets) –proven improvements in compliance Drugs (Rx-Rx, Rx-disease, Rx-allergy) –proven reduction in medication errors –proven improvements in compliance

23. Micromedex

24. Micromedex

25. Antibiotic use Use of physician order entry with clinical decision support resulted in: 75% fall in inappropriate Vancomycin use 48% fall in VRE case rate The local experience...

26. C difficile falls after CTX banned

27. … and it’s cheaper!

28. Consequences

29. Points to ponder Clinician ‘buy-in’: A fragile relationship? Systems medicine: A Brave New World? Changing clinical practice: An uphill battle?

30. Results Acknowledgement Paper filing at SCGH circa 2011

31. Results Acknowledgement > 90% acknowledged electronically in August