How KM can help cure medical errors
Through improved delivery of medical information and expanded use of mobile technology, KM is helping to reduce errors and improve patient care.
Maybe this will put the problem in perspective: Medical errors in hospitals cause as many deaths each year as would 500 airline crashes--up to 100,000, according to the Institute of Medicine (iom.org). Estimates from other studies place the toll even higher. These numbers do not include fatal medical errors in settings outside of hospitals, such as outpatient clinics, nor do they include non-fatal outcomes such as injury or disability.
The IOM's 1998 landmark study, "To Err Is Human," identified the fragmented nature of medical information systems and the difficulty of providing "timely access to complete patient information" as obstacles to patient safety. The study also cited the need for better dissemination of medical information. Yet according to a more recent IOM study, "Crossing the Quality Chasm," adoption rates for comprehensive electronic health records systems are very low, and IT infrastructures remain inadequate.
Knowledge management has an important role to play in reducing errors in many contexts, from monitoring product recall information to presenting current medical research and patient data. In few other settings is it more important to provide the "right information to the right people at the right time."
Johns Hopkins Hospital (JHH) received a wakeup call several years ago when doctors noticed an increase in infection rates among patients who had undergone a diagnostic procedure involving a bronchoscope. After testing the equipment, the staff discovered contamination caused by a loose port. They should have known sooner that the bronchoscope was defective, because a nationwide recall had already been issued. But the manufacturer's alert, delivered to a loading dock at the hospital, never reached the individuals who were responsible for taking action. Moreover, the alert was not posted on the relevant FDA Web site until many months after the initial recall was issued. Four hundred patients were affected by the defective bronchoscopes.
Managing medical alerts
JHH and Johns Hopkins Health System (JHHS) moved aggressively to follow up with patients who were potentially affected, and subsequently revised the entire process for handling medical alerts.
"We realized that no one understood what was supposed to happen with the alerts, or who was responsible for them," says Wayne Sparkes, director of business process redesign at Johns Hopkins. One problem was that the 3,000 alerts that arrive at the hospital each year originate from many sources and are delivered in many formats. Some are letters sent to doctors, some are sent by fax to the purchasing department. Others may be communicated through a phone call, an e-mail or a Web site. Sometimes alerts are received that have no relevance to the facility.
In the course of exploring possible solutions, JHH was approached by Mitretek Systems, which had seen a similar problem in other organizations. Mitretek, a non-profit scientific research and engineering corporation, was interested in determining whether KM solutions could resolve the problems inherent in the process. Mitretek and the Johns Hopkins Center for Innovation in Quality Patient Care (CIQPC) collaborated to develop RASMAS into a Web-based subscription service, which was formally introduced in 2004. It is now being used in approximately 100 U.S. hospitals. The system manages and distributes healthcare product alerts and recalls, and provides the workflow to track the hospital's response.
RASMAS collects alerts from numerous sources, standardizes the information into a consistent format and sends an alert via e-mail to the responsible individual.
Finding the right contact
"Without an automated system, most hospitals average 15 to 30 days to close an alert," says Ann Magee, RASMAS marketing manager, "but with RASMAS, the average is less than four days." That interval is being reduced further as detailed information for each domain of alerts (e.g., biomedical, blood, pharmaceuticals) is utilized to refine the process. The interval between the time an alert is issued and the time the hospital takes action represents an at-risk window to patients, visitors or staff for potential injury or death, so shortening it has a direct impact on patient safety.
"All user actions taken are documented in the system," adds Magee, "including how many items were found and what was done with them--a full history of the recall as it is processed by the hospital."
The RASMAS solution has now been implemented throughout JHHS. However, in order to make effective use of the system, JHHS had to go through an extensive discovery process to determine who should be responsible for each type of alert. Now that the contact points are established, the flow is tightly controlled.
"If the responsible person does not act within two days, they get a second notice," says Sparkes. "Two days after that, the alert goes to risk management, and then to legal, ensuring visibility and action within the organization." RASMAS meets the requirements for an alert and recall process set by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), which sets performance standards for healthcare facilities.
RASMAS has reduced workloads at JHHS by eliminating duplicate notices and sending each of the coordinators only those alerts that apply to their domain. Alerts are prioritized according to their level of urgency. Administrative time to process alerts has been reduced from about 25 hours to two or three hours. JHHS has also started to use RASMAS to distribute internally-generated alerts, in cases when the staff spots problems before they have been reported by manufacturers. A RASMAS user group is being established to allow coordinators and risk managers to collaborate on how to better manage alert information.
Keeping current
A recognized source of medical errors is the long delay in moving research results that reflect the best available medical knowledge into daily practice. Evidence-based medicine (EBM) or evidence-based decision-making, advocated by the Institute of Medicine studies, relies on having good access to the latest body of research. EBM is focused on the explicit use of the best current evidence and patient values in making decisions about the care of individual patients. However, with textbooks at least five years out of date, bringing such evidence to new doctors is a challenging proposition.
"Studies have shown that the treatment selected for hypertension by a given physician is correlated with the year the physician graduated from medical school," asserts Dr. R. Eugene Bailey, assistant professor in the Department of Family Medicine at SUNY Upstate Medical University. "Physicians need to update medical evidence into their practices at a much faster rate than they have in the past."
As part of his interest in converting medical research into practice, Bailey began using a handheld device that contained reference documents. He is now an enthusiastic user of Skyscape, a solution that delivers up-to-date medical reference material on Palms and Pocket PC devices.
"Skyscape can reduce medical errors by making medical reference information available to physicians at the point of decision, when they are with patients," says Bailey. "In addition, because Skyscape updates the materials continually, the references are current." Bailey uses his PDA frequently during the day, to teach students and residents, diagnose illnesses, determine treatment and obtain information about drugs.
The aspect of Skyscape that most differentiates it from other products and provides the greatest value-added, according to Bailey, is its linking technology. If a doctor looks up a drug in the "Physician's Desk Reference," a Links button appears that might reveal, for example, that there was a medical alert about the product. The links are updated every time the handheld device is synchronized over the Internet to add new data to the references. Those connections reflect the associative way in which doctors' thoughts move through an analytical process, and eliminate the need to move from one application to another.
"A lot goes on behind the scenes to manage these links," says R.J. Mathew, VP for marketing and business development at Skyscape, "because they are not hard-wired, as HTML links would be." Instead, the text from electronic references is run through a set of intelligent parsing systems that decompose the content, and rule-based systems then analyze it. Skyscape has been working for more than a decade on the underlying technology; the product was introduced in 2000. "Since a great deal of metadata is associated with a given piece of content," continues Mathew, "it interacts with the body of knowledge in an intelligent and dynamic way to make logical connections."
PDAs are also bringing patient information to doctors at the patient's bedside in the hospital. Having that information at hand contributes to patient safety both directly and indirectly. Doctors can base decisions on the most up-to-date information, such as updated medication histories. In addition, reducing the time spent on manually retrieving patient histories saves hours each week, and frees up time for doctors to focus on their primary functions of diagnosis and treatment.
"With manual systems, getting lab results involves multiple steps, including having faxes sent from the lab, retrieving them at a station near the patient and placing them on patient charts," says Dr. Darrick Nelson, assistant professor of family practice in the CHRISTUS Health System. "A breakdown at any point can prevent critical information from reaching the doctor." Delivery from the lab directly to a doctor's PDA eliminates all the interim steps and ensures that the data will arrive promptly.
CHRISTUS Spohn, which has three hospitals in Corpus Christi and three in south Texas, began using a mobile computing solution from PatientKeeper at the end of 2003 to provide clinical data about patients. The number of doctors using the system as well as the types of patient information have been increasing steadily ever since. Information such as lab results, microbiology reports, drugs, patient allergies, operative progress and other medical reports, and demographic and administrative data are accessible through the system.
The PatientKeeper system has been well received by physicians, who attended "open houses" that described the planned implementation and how they could participate. Nelson, who is responsible for 36 residents in the hospital, gets new users up and running quickly. "The first thing I do is set them up with a handheld," says Nelson. Before the hospital implemented PatientKeeper, Nelson was using a personal version of the product to manage his work more efficiently. He is firmly convinced of the value for patient safety. "PatientKeeper keeps track of drug interactions and patient allergies," he adds, "and my notes about patients are always legible to consultants and nurses."
PatientKeeper's mobile platform not only delivers patient-related data to the physicians while in the hospital, but can also serve as the common denominator across multiple information systems--even across multiple hospitals.
"The fact is many hospitals have already invested tens of millions of dollars in clinical information technology," says Stephen S. Hau, founder and VP of marketing and business development at PatientKeeper. "Unfortunately, these systems are often not fully utilized. Many clients have discovered that mobile devices using PatientKeeper provide the accessibility and simplicity to drive the acceptance of these underlying information systems. " In addition to delivering clinical results, PatientKeeper can also capture charges, dictate notes, write electronic prescriptions and access reference materials.
Patient Centered Care
New KM methods and technologies will be critical to the development of the patient-centered care that will reduce medical errors, according to Dr. Charles Denham, who is chairman of the Texas Medical Institute of Technology (TMIT) and a member of the board of the National Patient Safety Foundation (NPSF, npsf.org). Today's healthcare system is production-centered rather than patient-centered, a model that creates fragmentation from the patient perspective. Therefore, no single healthcare professional can see a complete picture of a patient's care path.
"A breakdown can easily occur during handoffs as patients proceed from one part of the system to another," says Denham. "Many failures in patient care come from these transitions."
KM suppliers of products, services and technologies should move from a "feature-function" value proposition to an evidence-based solution proposition, according to Denham. "Explain what the technology can do to improve care," he challenges suppliers, "don't just offer features and functions at the lowest price." Healthcare providers, for their part, need to ask how KM technologies can close the performance gaps for quality and safety, particularly with respect to integrating patient information and processes. With patient-centered care in place, coordination among providers should be dramatically improved.
KM can also help prevent outdated medical knowledge from being applied in practice. "Our 17-year innovation adoption rate from research evidence to frontline practice is outrageous," says Denham. He cites the value of communities of practice in accelerating innovation adoption. "Better sharing of information leads directly to better performance," he says. Communities of practice are well supported by established KM technologies, and have much to offer in reducing errors that result from the failure to apply current medical knowledge.
Judith Lamont is a research analyst with Zentek Corp., e-mail jlamont@sprintmail.com.