2. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Improving Patient Safety with Information and Communication Technology Wanfang’s Experience with the High Risk Reminder System Improving Patient Safety with Information and Communication Technology Wanfang’s Experience with the High Risk Reminder System 李友專,M.D., Ph.D. 台北醫學大學‧萬芳醫院 台北醫學大學醫學資訊研究所 李友專,M.D., Ph.D. 台北醫學大學‧萬芳醫院 台北醫學大學醫學資訊研究所

3. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University

4. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Current State of Healthcare n Care is complex n Care is uncoordinated n Information is often not available to those who need it when they need it As a result patients often do not get care they need or do get care they don ’ t need n Care is complex n Care is uncoordinated n Information is often not available to those who need it when they need it As a result patients often do not get care they need or do get care they don ’ t need IOM, Crossing the Quality Chasm

5. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Medical Errors Adverse Event (Iatrogenic Injury) Near Misses Preventable Adverse Events Preventable by training, protocol, systematic monitoring and Information Technology (20~30%) Sentinel Events Negligence Sub-standard care, legal criteria No harm done Caused death or permanent loss of function, reportable

6. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University J.Reason, BMJ 2000;320:768-770 The Swiss Cheese Model of System Accidents

7. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Preventable? By IT?

8. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Main Strategies for Preventing Errors and AEs Using IT n Tools to improve communication n Making knowledge more readily accessible n Assisting with calculations n Performing checks in real time n Assisting with monitoring n Providing decision support n Tools to improve communication n Making knowledge more readily accessible n Assisting with calculations n Performing checks in real time n Assisting with monitoring n Providing decision support Bates and Gawande, NEJM 2003

9. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University IT infrastructure for Patient Safety n Electronic Medical Record (EMR) n Computerized Physician Order Entry (CPOE) n Clinical Decision Support System (CDSS) and Reminder System n Electronic Medical Record (EMR) n Computerized Physician Order Entry (CPOE) n Clinical Decision Support System (CDSS) and Reminder System

10. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Evidence After implementation of Clinical Decision Support System (CDSS)

11. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University What data do we have?

12. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Patient Profile Diagnosis & History Procedures Medication Laboratory Data 12 9 7 8 5 1 11 10 4 3 2 Age, sex, allergy, weight, height, blood type, body temperature, …etc. YC Li et. al., 2004 Current and/or chronic dz, DM, H/T, Pregnancy…etc. Surgery, transfusion, endoscopy, angiogram, PTCA, rehabilitation…etc. Propanolol vs theophylline, Cipro vs aminophylline, Acetaminophen vs Phenytoin…etc. CBC, D/C, Chem- 20, hCG, PT, APTT, INR…etc. e.g. Coumadin vs INR e.g. Wafarin vs angiogram e.g. Penicillin vs PCN allergy e.g. Retinoids vs pregnancy Data Interaction Model for AE detection

13. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University All Possible Data Interactions n One-way: 5 (e.g. Drug-Drug) n Two-Way: 10 (e.g. Drug-Lab) n Three-Way: 10 (e.g. Drug-Lab-Person) n Four-Way: 5 (e.g. Drug-Lab-Person-Proc) n Five-way: 1 (Drug-Lab-Person-Proc-Dx) n One-way: 5 (e.g. Drug-Drug) n Two-Way: 10 (e.g. Drug-Lab) n Three-Way: 10 (e.g. Drug-Lab-Person) n Four-Way: 5 (e.g. Drug-Lab-Person-Proc) n Five-way: 1 (Drug-Lab-Person-Proc-Dx)

14. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Where to Start?

15. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University

16. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University JCAHO 2004 Patient Safety Goal n Improve the accuracy of patient identification n Improve the effectiveness of communication among caregivers n Improve the safety of using high-alert medications n Eliminate wrong-site, wrong-patient, wrong-procedure surgery n Improve the effectiveness of clinical alarm systems n Reduce the risk of health care-acquired infections n Improve the safety of using infusion pumps n Improve the accuracy of patient identification n Improve the effectiveness of communication among caregivers n Improve the safety of using high-alert medications n Eliminate wrong-site, wrong-patient, wrong-procedure surgery n Improve the effectiveness of clinical alarm systems n Reduce the risk of health care-acquired infections n Improve the safety of using infusion pumps

17. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Current Systems in WFH

18. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 推動病人安全之行政架構

19. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 病安資 訊中心 Knowledge Interface Engine 病安知識庫 Patient Safety Requirement Questionnaire Interview and patient safety requirement analysis Rule description framework PSI Center operations Collect Transform 由各臨床 科填寫 3-year Retro -spectiveDatabase 病安執行小 組 醫囑系統 Trial Run Online Reminders 病安資訊中心 Patient Safety Informatics

20. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Patient Safety Information Systems n HRR (High Risk Reminder and Monitor) ä 高風險自動警示暨監測系統 n 用藥安全資訊系統 ä 藥物交互作用提示暨回應系統 ä 懷孕用藥提示系統 n 外科病人安全系統 n AERS 不良事件通報系統 ä 藥物不良事件、針扎、拔管、跌倒事件通報 n HRR (High Risk Reminder and Monitor) ä 高風險自動警示暨監測系統 n 用藥安全資訊系統 ä 藥物交互作用提示暨回應系統 ä 懷孕用藥提示系統 n 外科病人安全系統 n AERS 不良事件通報系統 ä 藥物不良事件、針扎、拔管、跌倒事件通報

21. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Lab Data and Exam Report n Average time for a critical lab data to be reviewed by a physician: ä 30 hours !!! n Average time for an exam report to be read by a physician: ä One week !!! n Average time for a critical lab data to be reviewed by a physician: ä 30 hours !!! n Average time for an exam report to be read by a physician: ä One week !!!

22. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 高風險檢驗檢查報告提示系統 High Risk Reminder (HRR) n 對醫院病人的專業貢獻及付出，讓醫院的醫療 品質更加完備 n 讓各位醫師們在照顧之餘，便利與病人醫療資 料保持即時性溝通，讓您可以隨時掌握病人醫 療狀況 n 設計一套『高危險檢驗檢查報告提示系統， High Risk Reminder - HRR 』 n 透過 PHS 手機及電子郵件來通報各主治醫師 n 對醫院病人的專業貢獻及付出，讓醫院的醫療 品質更加完備 n 讓各位醫師們在照顧之餘，便利與病人醫療資 料保持即時性溝通，讓您可以隨時掌握病人醫 療狀況 n 設計一套『高危險檢驗檢查報告提示系統， High Risk Reminder - HRR 』 n 透過 PHS 手機及電子郵件來通報各主治醫師

23. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 高危險檢驗檢查報告提示系統 High Risk Reminder HRR n 通報閾值是由檢驗科、放射科、病理科、內 視鏡室分別以國內檢驗檢查標準，來維護每 一項目危及生命的危險值 ( 不是只超過正常範 圍 ) 。 n 為各科的整體照護，以及讓各科部主任更能 掌握該科的狀況，簡訊發送除了開單主治醫 師之外，另會發送給科主任及部主任 n PHS 手機簡訊傳送簡要的高危險報告內容， 電子郵件則會發送完整的資訊 n 通報閾值是由檢驗科、放射科、病理科、內 視鏡室分別以國內檢驗檢查標準，來維護每 一項目危及生命的危險值 ( 不是只超過正常範 圍 ) 。 n 為各科的整體照護，以及讓各科部主任更能 掌握該科的狀況，簡訊發送除了開單主治醫 師之外，另會發送給科主任及部主任 n PHS 手機簡訊傳送簡要的高危險報告內容， 電子郵件則會發送完整的資訊

24. High Risk Reminder and Surveillance Department directors Physician s Nurses Department secretary e-mail complete info. PHS short msg. HRR Monitor Radiology Report Lab Results Pathology Report HRR Knowledge Base and Engine Patient Safety

25. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University HRR (High Risk Reminders) n Reminder Type ä For Physicians: PHS- 即時簡訊, e-mail ä For Nurses: Web-based HRR monitor n Reminding Domains ä Critical lab data –31 extreme values (CAP definitions) + 590 pathogens ä Critical Radiology report ä Critical Pathology report n Reminder Type ä For Physicians: PHS- 即時簡訊, e-mail ä For Nurses: Web-based HRR monitor n Reminding Domains ä Critical lab data –31 extreme values (CAP definitions) + 590 pathogens ä Critical Radiology report ä Critical Pathology report

26. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 檢驗結果危險值表 CAP (College of American Pathologist)

27. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University PHS HRR sample

28. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University E-mail HRR sample

29. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 高風險自動警示系統 E-mail畫面-Lab檢驗

30. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 高風險自動警示系統 E-mail畫面 RAD檢驗

31. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 高風險自動警示系統 E-mail畫面 PATH檢驗

32. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University 高風險自動警示系統畫面

33. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Lab HRR 通報類別月分析

34. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Lab HRR Ratio

35. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Path HRR Monthly Report

36. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University RAD HRR Monthly Report

37. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University (Source: DeLone & McLean, 1992) Evaluation of the HRR System

38. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University The D & M model and hypotheses System Quality Info. Quality System Use Individual Impact Organization Impact User Satisfaction H5 H4 H3 H1 H2

39. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University The D & M model and hypotheses n H1. System quality and information quality have effects on system use. n H2. System quality and information quality have effects on user satisfaction. n H3. System use has an effect on user satisfaction. n H4. System use and user satisfaction have effects on individual impact. n H5. Individual impact has an effect on organization impact. n H1. System quality and information quality have effects on system use. n H2. System quality and information quality have effects on user satisfaction. n H3. System use has an effect on user satisfaction. n H4. System use and user satisfaction have effects on individual impact. n H5. Individual impact has an effect on organization impact.

40. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Respondents n 56 Attending Physicians in WFH accepted the test n Each answered 36 survey questions in the questionnaire (about 10 minutes to complete) n 7 physicians rarely received HRR and were removed to assure validity. n Effective sample size = 49 n 56 Attending Physicians in WFH accepted the test n Each answered 36 survey questions in the questionnaire (about 10 minutes to complete) n 7 physicians rarely received HRR and were removed to assure validity. n Effective sample size = 49

41. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Answers to the Questionnaire

42. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Hypothesis Testing Hypotheses Beta 結果 Information quality 0.704*** significant H1 System quality  System use 0.049 Information quality 0.813*** significant H2 System quality  User satisfaction 0.054 H3 System use  User satisfaction 0.886*** significant User satisfaction 0.711** significant H4 System use  Individual impact -0.96 H5 Individual impact  Organizational impact 0.617*** significant *p < 0.05; ** p < 0.01; *** p < 0.001

43. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Results n HRR improves communication efficiency between colleagues: 3.73(±0.58) n HRR improves patient safety: 4.03(±0.49) n HRR improves quality of care for the critically-illed: 4.03(±0.41) n HRR improves communication efficiency between colleagues: 3.73(±0.58) n HRR improves patient safety: 4.03(±0.49) n HRR improves quality of care for the critically-illed: 4.03(±0.41)

44. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Discussion n HRR is well-received among most physicians n HRR can improve patient safety and quality of care n Information quality is more important than system quality n HRR is well-received among most physicians n HRR can improve patient safety and quality of care n Information quality is more important than system quality

45. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Conclusion

46. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University

47. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Questions and Comments http://gimi.tmu.edu.tw/ http://li.tmu.edu.tw

48. Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Questions and Comments