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.