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PANEL DISCUSSION: Global perspective on using IT to measure and improve quality and safety

By Andrew Kanter, MD MPH | 26 Sep, 2010 Last edited by Robert Szypko on 02 Aug 2011

Medinfo 2010 was held in Cape Town, South Africa from September 12-15, 2010. It was very well attended with representation from many countries, particularly from Africa. It was an excellent opportunity to bring the world of health informatics to the continent of Africa. A lot of exciting informatics activities have been brewing in Africa and in Global South countries for the past several years. It is particularly appropriate that Medinfo should come to Africa at the 10 year anniversary of UN promise on the Millennium Development Goals. The American Medical Informatics Association annual meeting will be held in Washington, DC from November 13-17, 2010. This close approximation of these two important meetings provides an opportunity to build upon the momentum begun before Cape Town to achieve an inclusive global informatics effort, particularly to serve those in resource-poor settings.
 
This discussion panel will be on the global perspectives on the role of health informatics on improving quality and safety. It will take place formally between September 27th and October 8th. It will take place simultaneously here and at http://grou.ps/medinfo2amia2010/talks/4047835 and atWe are grateful to have three panelists who will be online to facilitate the discussion. The panel will consist of the following:
 
Andrew S. Kanter, MD MPH- Moderator. Director of Health Information Systems/Medical Informatics for the Millennium Villages Project at the Earth Institute, Columbia University and Assistant Professor of Clinical Biomedical Informatics and Clinical Epidemiology at the Earth Institute.
 
David W. Bates, MD MSc- Panelist. Chief, Division of General Internal Medicine, Brigham and Women's Hospital, Boston. Professor of Medicine, Harvard Medical School, Professor of Health Policy and Management at the Harvard School of Public Health and Director of the Center for Patient Safety, Research and Practice at Brigham and Women's Hospital and Harvard Medical School.
 
Jean Marie Rodrigues, MD - Panelist. Founding Chair of the Department of Public Health and Medical Informatics at the University of Saint Etienne Hospital, France. WHO Collaborating Center for International Classifications in French Language, Paris, France, and WHO collaborator for International Classification of Diseases, 11th Edition (ICD 11) and International Classification of Patient Safety (ICPS).
 
Dean Sitting, PhD - Panelist. Professor, School of Biomedical Informatics, The University of Texas Health Science Center at Houston. Member University of Texas, Houston-Memorial Hermann Center for Healthcare Quality and Safety.
 
Discussion Topic:
What is the role of international health informatics in improving quality and safety, particularly in low-resource settings?
 
As director of a program to implement health information systems in rural Africa, as part of an overall, integrated development effort to lift villages out of poverty and help countries achieve the Millennium Development Goals, this is a particularly important topic for me. We are implementing an open source stack of applications called the Millennium Global Village-Network (MGV-Net) which includes both the mobile device, RapidSMS-based system known as ChildCount+ and the electronic medical record framework known as OpenMRS. We believe that providing Information and Communication Technology (ICT) at the point-of-care, can markedly improve our ability to monitor and evaluate health care delivery in the most disadvantaged of populations, while improving the quality of care of the patients and the quality of life of the providers. Including Community Health Workers (CHWs), Nurses, Clinical Officers as well as Doctors in our health information systems offers the opportunity to effect positive changes where they are needed most (while at the same time providing more timely and accurate information to program administrators and Ministries of Health for planning purposes). Africa and other similar environments provide both challenges and opportunities. Most of these are beyond the scope of this discussion, but in particular, I wonder if the panel would provide some initial thoughts, and answers to some questions to get the discussion going.
 
1. What are the most important areas for newly innovating health systems to focus on to ensure quality of care and patient safety, particularly as applied to the Global South?

2. What special considerations are needed when taking Quality/Safety lessons from existing health information systems and applying them in these settings?

3. How do we ensure scalability and sustainability of Quality/Safety-focused systems when dealing with resource-poor settings?

Come back tomorrow for the beginning of the discussion!

Replies

 

Neelam Adhikari Replied at 1:14 AM, 27 Sep 2010

Looking forwaed to it.

Neelam

--
Neelam Adhikari MD
Rector
Patan Academy of Health Sciences
P.O.Box#26500
Kathmandu,Nepal
Tel: +977-1-5545112
Cell: 98510-53122
Fax: +977-1-5545114
Office secretory: Sushila Rai
Tel:+977-1-5545112
Web: www.pahs.edu.np

Andrew Kanter, MD MPH Replied at 7:58 AM, 27 Sep 2010

I will now provide some introductory thoughts from our panelists, which will be followed by their responses to the first questions I posed. Please follow along and contribute questions or comments!


David Bates, MD MSc:

Information technology has tremendous potential to improve safety in healthcare from a number of perspectives, but this potential is just now beginning to be realized. Not surprisingly, many of the presentations at Medinfo in Cape Town related to this. Among the areas that appeared to receive a lot of attention were computer order entry; surveillance for adverse events, especially adverse drug events and health-care associated infections; and discussion of medication-related decision support. One exciting development was the presentation of the ICPS, the International Classification of Patient Safety, which has been developed by the World Alliance for Patient Safety of the World Health Organization. There was also a continuing focus on the unintended consequences of information technology, some of which have safety implications.
Other areas which should perhaps receive more attention in the future include evaluation of the impact of clinical data exchange on patient safety, using IT to routinely measure the frequency of adverse events beyond adverse drug events and infections, the use of national and regional systems to detect safety issues, and more evaluations of the use of HIT to improve safety directly.
Overall, the intersection between HIT and safety continues to be a very hot area, and there will undoubtedly be some interesting work presented at AMIA on this topic.

Andrew Kanter, MD MPH Replied at 7:59 AM, 27 Sep 2010

Dean F. Sittig, Ph.D.
Professor, School of Biomedical Informatics , The University of Texas Health Science Center at Houston
Member, University of Texas, Houston-Memorial Hermann Center for Healthcare Quality and Safety
My research interests center on the design, development, implementation, and evaluation of all aspects of clinical information systems. In addition to my work on measuring the impact of clinical information systems on a large scale, I am also working to improve our understanding of both the factors that lead to success, as well as, the unintended consequences associated with computer-based clinical decision support and provider order entry systems.
As I get older, I am beginning to realize that many of the difficulties we have had, and continue to have, in implementing and moving health information technology (HIT) projects from the “prototype” stage into the routine healthcare delivery process is due to the paucity of theoretical or conceptual models that could help us understand the complex socio-technical interactions between the hardware, software, people, and processes involved.
Towards that end, we have developed a new, 8-dimension, socio-technical model of safe and effective health information technology implementation and use. The 8 dimensions are not independent, sequential, or hierarchical, but rather are interdependent and interrelated concepts similar to compositions of other complex adaptive systems. Hardware and software computing infrastructure refers to equipment and software used to power, support, and operate clinical applications and devices. Clinical content refers to textual or numeric data and images that constitute the “language” of clinical applications. The human computer interface includes all aspects of the computer that users can see, touch, or hear as they interact with it. People refers to everyone who interacts in some way with the system, from developer to end-user, including potential patient-users. Workflow and communication are the processes or steps involved in assuring that patient care tasks are carried out effectively. Two additional dimensions of the model are internal organizational features (e.g., policies, procedures, and culture) and external rules and regulations, both of which may facilitate or constrain many aspects of the preceding dimensions. The final dimension is measurement and monitoring, which refers to the process of measuring and evaluating both intended and unintended consequences of HIT implementation and use.
One of the most important aspects of this model is that one must address ALL 8 dimensions of this model before a successful and sustainable HIT system can be achieved. Failure to satisfactorily address even 1 dimension of this model is a surefire ticket to failure. I believe that this tightly interconnected model helps explain why it is so difficult to move beyond the “prototype” stage in many HIT projects; be they implemented in fully developed or developing nations. Specifically, it is difficult for one person or even a small team to be skilled enough to navigate all of these socio-technical areas to insure that everything required for successful HIT implementation is in order.

Andrew Kanter, MD MPH Replied at 8:05 AM, 27 Sep 2010

Dr. Jean Marie Rodrigues: Preliminary thoughts on the three questions:

1. What are the most important areas for newly innovating health systems to focus on to ensure quality of care and patient safety, particularly as applied to the Global South?

This question need to be answered to identify first the most important
goals of the health care systems of this countries which are not necessarly
the same as for more developed countries. for instance is the access equity
or the access itself of the population an important goal compare to insure
patient care quality and safety?

2. What special considerations are needed when taking Quality/Safety lessons from existing health information systems and applying them in these settings?

The main lesson is that we have to extract the most efficient process for
these countries and probably not all of them.

3. How do we ensure scalability and sustainability of Quality/Safety-focused systems when dealing with resource-poor settings?

It is probably a world community responsibility to help these countries
for sustainability and to follow their opinion for scalability with caution.

A/Prof. Terry HANNAN Moderator Replied at 8:13 AM, 27 Sep 2010

All, thse comments by David are very relevant to where I am located at the moment in the Department of Pediatric Hematology and Oncology in Modena Italy. Last week i found on the WHO site a classification for functionality that has important relevance to assessing the functionality of children (all ages) post pre-term birth and chemotherapy. The deparment here wants to provide some measure of outcomes based not on survival alone. I hope this si a suitable contribution to this discussion. Terry Hannan

ICF CHECKLIST-(from WHO)

(International Classification of Functioning, Disability and Health)

Version 2.1a, Clinician Form:



http://apps.who.int/classifications/icfbrowser/Default.aspx [Select Children's and Youth version from Language/Version box.


Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
Consultant Physician
Clinical Associate Professor School of Human Health Sciences, University of Tasmania
Department of Medicine, Launceston General Hospital Charles Street Launceston 7250
President Australasian College of Health Informatics(2007-9)
Visiting Professor Universita Degli Studi, Dr Modena e Reggio Emelia, Italy. Sep-Nov 2010
Ph. +61 3 6348 7578
Mob. 0417 144 881
Fax + 61 3 6348 7577
Email


CONFIDENTIALITY NOTICE AND DISCLAIMER

The information in this transmission may be confidential and/or protected by legal professional privilege, and is intended only for the person or persons to whom it is addressed. If you are not such a person, you are warned that any disclosure, copying or dissemination of the information is unauthorised. If you have received the transmission in error, please immediately contact this office by telephone, fax or email, to inform us of the error and to enable arrangements to be made for the destruction of the transmission, or its return at our cost. No liability is accepted for any unauthorised use of the information contained in this transmission. If the transmission contains advice, the advice is based on instructions in relation to, and is provided to the addressee in connection with, the matter mentioned above. Responsibility is not accepted for reliance upon it by any other person or for any other purpose.

A/Prof. Terry HANNAN Moderator Replied at 8:22 AM, 27 Sep 2010

Dean, the following comment caught my eye.
"I am beginning to realize that many of the difficulties we have had, and continue to have, in implementing and moving health information technology (HIT) projects from the "prototype" stage into the routine healthcare delivery process is due to the paucity of theoretical or conceptual models that could help us understand the complex socio-technical interactions between the hardware, software, people, and processes involved."
Has not this been done in industry at all levels? This begs the question does health care delivery have additional more complex less understood socio-technical issues than "industries"? As Warner Slack has indicated, "Medicine is not a business. Our business is clinical medicine."

Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
Consultant Physician
Clinical Associate Professor School of Human Health Sciences, University of Tasmania
Department of Medicine, Launceston General Hospital Charles Street Launceston 7250
President Australasian College of Health Informatics(2007-9)
Visiting Professor Universita Degli Studi, Dr Modena e Reggio Emelia, Italy. Sep-Nov 2010
Ph. +61 3 6348 7578
Mob. 0417 144 881
Fax + 61 3 6348 7577
Email


CONFIDENTIALITY NOTICE AND DISCLAIMER

The information in this transmission may be confidential and/or protected by legal professional privilege, and is intended only for the person or persons to whom it is addressed. If you are not such a person, you are warned that any disclosure, copying or dissemination of the information is unauthorised. If you have received the transmission in error, please immediately contact this office by telephone, fax or email, to inform us of the error and to enable arrangements to be made for the destruction of the transmission, or its return at our cost. No liability is accepted for any unauthorised use of the information contained in this transmission. If the transmission contains advice, the advice is based on instructions in relation to, and is provided to the addressee in connection with, the matter mentioned above. Responsibility is not accepted for reliance upon it by any other person or for any other purpose.

Om G Replied at 1:59 PM, 27 Sep 2010

Is there a published resource discussing the 8 Dimensional Model?



om

Andrew Kanter, MD MPH Replied at 2:23 PM, 29 Sep 2010

Reply from Dean Sittig:

There is: Dean F. Sittig, PhD; Hardeep Singh, MD, MPH. Eight Rights of Safe Electronic Health Record Use JAMA. 2009;302(10):1111-1113.
I'd be happy to send you a copy if you can't get one (dean.f.sittig at uth.tmc.edu). We have another more detailed paper coming out in Quality and Safety in Healthcare very soon. I'd send you a pre-print of that too if you wanted.

Andrew Kanter, MD MPH Replied at 2:24 PM, 29 Sep 2010

Another reply from Dean Sittig:

In response to Terry Hannan who asked..."Has not this been done in industry at all levels? This begs the question does health care delivery have additional more complex less understood socio-technical issues than "industries"?
I don't know if it has more or less of these S-T issues, but I don't think we regularly think about all of them the way that others do. Take Apple for example, their Ipod, iPhone, iPad trifecta which is due as much to hardware and software as it is to content (think itunes and app stores), internal policies and procedures (think how they "police" all the apps that are available), and the User Interface. To think that anyone of these is more important than the others is wrong. Others have many of the same, but not all, the same features, functions, content etc. but it is the way that they put it all together that makes their greatness.

Likewise in informatics...we have developed many different systems, features, interventions with wildly different results and we don't really know why some systems work well in some organizations and poorly in others...remember Han et al's Unexpected increased mortality after implementation of a commercially sold computerized CPOE. And Del Beccaro et al's
CPOE Implementation: No Association With Increased Mortality Rates in an Intensive Care Unit. Clearly there was something different between these 2 implementations other than software, but we don't really know for sure...I might venture: content, internal policies and procedures, perhaps even the hardware infrastructure.

Another example along these lines could be the CPRS system in use at VA hospitals across the USA. This software has been very successful for many years. Even though this software is now available as opensource very few organizations are using it, compared to how successful it has been in the VA. Why not?

So my point is...when we start to think about appropriate hardware and software implementations to improve quality and safety of healthcare in developing nations, we must also think about the where and what content they will use, how the User Interface will look and feel, who will implement, provide training, and use the system, how will it impact the existing communication and workflows in the clinic, do they have the appropriate internal policies and procedures in place to allow the system to work and what are the external rules and regulations that govern the healthcare system and eventually provide the financing to sustain the system. Without considering all of these dimensions, the project is destined to languish at the prototype stage.

Steven Wanyee Macharia Replied at 3:21 AM, 30 Sep 2010

Andrew, I think the 8 dims are very apt but one thing that I have constantly grappled with working at various levels and interacting with actors playing different roles of services provision in healthcare is one of culture and attitude. It has been drummed over and over again that at the end of the day, positively influencing the entire continuum of health services provision on the value of health data/information is key and central to attaching a priceless value on data; everything else in terms of the structure and systems that support generation and use of health data/info can only follow that in that order. That is not to say or discount that there are obviously efforts that continue to function in parallel and the complexity of achieving that goal demands for that anyway. In Africa and specifically my home country Kenya for example, it is not a natural culture for us to associate the question "how do you know" for any statement, allegation or declaration made with a demand for objective evidence.The natural tendency is to associate that more with authority (the source in form of human being of that statement, allegation, declaration) - and not to say that authority and evidence are necessarily mutually exclusive because they certainly complement each other in certain cases. The point I'm trying to make in my long winded way is that slicing through the contents of the 8 dims and other descriptions and popular discussions about getting systems to work safely and effectively, lies at the core something inside people that should enable them to associate a value and outcome of a process.

A/Prof. Terry HANNAN Moderator Replied at 5:22 AM, 30 Sep 2010

My response to Steven's valid statements are based on our initial experiences in Kenya (MMRS/AMPATH).
Bill Tierney and I "sat in the dirt" (physically and metaphorically) with the local end-users for soem 18 months and initlally 'fitted the information' using the technologies and knowledge we had into their normal workflow patterns. It 'appeared' as if they were doing the same activities as normally except in e-format.
Then we provided them with 'outputs' that demonstrated that they could easily 'measure' what they do.
For example, with 2 years of clinic data they recorded 0% HIV/TB diagnoses over 63,000+ patient visits.
The 'cultural change' as indicated by Steven was that the clinic staff became interogative of the clinical data (i.e. the information management system chnaged their behaviour). Some outcomes of this change were;

>From 2 weeks ? 1 hour to produce monthly MOH reports (#1 among rural health centers)

Document drug use ? order refills earlier

Quantify amount of free care provided ? increased funding from the Kenyan MOH

MOH advisory committee recommended that the MMRS be used in all rural health centers

Noted a village with too few children being vaccinated ? nurse sent to intervene: vaccinate, educate

Noted a village with too many STIs ? nurse sent to intervene: treat, educate

Noted many dog bites in one area ? rabid dog found biting dogs, humans ? destroyed



So in essence the information management "with end-user" involvement changed the social-clinical behaviours.

I hope this is a positive contribution to this discussion.


Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
Consultant Physician
Clinical Associate Professor School of Human Health Sciences, University of Tasmania
Department of Medicine, Launceston General Hospital Charles Street Launceston 7250
President Australasian College of Health Informatics(2007-9)
Visiting Professor Universita Degli Studi, Dr Modena e Reggio Emelia, Italy. Sep-Nov 2010
Ph. +61 3 6348 7578
Mob. 0417 144 881
Fax + 61 3 6348 7577
Email

Steven Wanyee Macharia Replied at 11:03 AM, 30 Sep 2010

I have a question to David Bates, is reduction of potential and/or actual risk posed to patients by HIT the same as using HIT to improve patient safety? do those two address the same thing?

Andrew Kanter, MD MPH Replied at 8:47 PM, 3 Oct 2010

Half way through the discussion on global informatics and patient safety and quality... Please check out the conversation here or on grou.ps!

Andrew Kanter, MD MPH Replied at 9:27 AM, 5 Oct 2010

Reply from David Bates:
Good question--they aren't the same thing in my view. HIT can affect safety overall, and can both prevent errors and harm, as well as raise the risk of harm. Some studies assess the net risk--that is to say, harm prevented less harm created. Many other recent studies have focused on harm created, or unintended consequences. When HIT is used to try to improve safety in an area, it makes sense to both measure the overall impact on safety, and also to assess the frequency of new problems created so these errors can be engineered out.

David Bates

Andrew Kanter, MD MPH Replied at 9:31 AM, 5 Oct 2010

David's answers to the three questions:


1. What are the most important areas for newly innovating health systems to focus on to ensure quality of care and patient safety, particularly as applied to the Global South?

I think that using low-cost solutions in creative ways is one of the top priorities. Many countries and organizations are delivering content and collecting data using cell phone technology, for example. It will also be possible to begin measuring data in much more routing ways. See also this paper we wrote on these issues, which has some good examples.
Evaluating eHealth: undertaking robust international cross-cultural eHealth research. (http://www.ncbi.nlm.nih.gov/pubmed/19753106)

Bates DW, Wright A.

PLoS Med. 2009 Sep;6(9):e1000105. Epub 2009 Sep 15. No abstract available. PMID: 19753106 [PubMed - indexed for MEDLINE]Free PMC ArticleFree text

2. What special considerations are needed when taking Quality/Safety lessons from existing health information systems and applying them in these settings?


One thing that is clearly important is designing simple interfaces that minimize the likelihood of error.


3. How do we ensure scalability and sustainability of Quality/Safety-focused systems when dealing with resource-poor settings?

This is a substantial challenge as both scalability and sustainability have been problematic. But keys include considering eventual scalability when picking interventions to begin with, and avoiding approaches that are simply too expensive or complex to be used widely. With sustainability as well as scalability, another approach which may be important is to include in an initial evaluation assessment of the relative costs and benefits of the intervention, which can be very important for prioritization later on. In some of our work with WHO patient safety, we have found that such evaluations are rarely done in resource-poor settings.

For a paper on priorities in patient safety research by level of development, see the following paper:

Global priorities for patient safety research. (http://www.ncbi.nlm.nih.gov/pubmed/19443552)

Bates DW, Larizgoitia I, Prasopa-Plaizier N, Jha AK; Research Priority Setting Working Group of the WHO World Alliance for Patient Safety.

BMJ. 2009 May 14;338:b1775. doi: 10.1136/bmj.b1775. No abstract available. PMID: 19443552 [PubMed - indexed for MEDLINE]

Leo Anthony Celi Replied at 1:20 PM, 5 Oct 2010

Hi, everyone,
 
I represent Sana (previously Moca), a volunteer organization hosted at MIT.  We
are in the process of developing a course on implementation and evaluation of
eHealth technologies. The initial course will be primarily didactic with a
strong emphasis on building information systems to facilitate the creation of a
culture of quality and safety in healthcare. Quality improvement concepts,
including the design of learning systems, application of industry tools such as
Lean Sigma, use of Plan-Do-Study-Act cycles for process optimization, Positive
Deviance, and systems approach to errors, among others, will be presented in the
context of ongoing eHealth projects. The course will be offered at MIT in 2011
and will be disseminated by the MIT Open Course Ware for free so that it can be
shared with healthcare organizations around the world. The subsequent iterations
of the course will be more project-oriented where the Boston-based students will
work with students from other countries incubating eHealth projects and under
the mentorship of faculty members from MIT, Harvard and Sana’s partner
universities, and local eHealth experts. Target students will come from
different disciplines to foster the same collaborative ecosystem that has worked
so well for our group. 

We are looking for e-Health organizations who may want to share their experience
in the context of specific quality improvement concepts outlined in the
syllabus.  Please contact me via email () if you are interested. 
Thank you.
 
Cheers,
Leo

Zach Landis-Lewis Replied at 1:23 PM, 5 Oct 2010

This looks like something we will want to take notes from.

Zach Landis-Lewis Replied at 1:58 PM, 5 Oct 2010

Apologies for the earlier misdirected message. Thank you to everyone who has already contributed to this important discussion.

In response to the first question: "1. What are the most important areas for newly innovating health systems to focus on to ensure quality of care and patient safety, particularly as applied to the Global South?" I would like to share a paper we recently published describing experiences implementing a point-of-care EMR in Malawi over the past eight years. From the paper:

"We believe that paper-based systems cannot work efficiently or accurately once large patient numbers are reached and that computerized systems are essential, a position supported by experienced practitioners in this field. Furthermore, we believe that the traditional approach to M&E where the M&E process exists as a separate layer or “wrapper” around the clinical process has several shortcomings. Recognizing that M&E data and patient care data are essentially one, we advocate an approach that tightly couples M&E and patient care processes, recording data once at the point-of-care (POC).

Here, we describe the rationale and experience of using a touchscreen electronic medical record (EMR) system at the POC to monitor and support ART scale-up in Malawi. The EMR eliminates the process of
manual updating of paper registers and data aggregation for cohort and survival analysis reports, and produces cohort reports at the touch of a button on the screen. We present a model, developed and refined in Malawi, that has the potential to improve data quality and clinical efficiency in low-resource settings by integrating EMR and M&E systems."

Douglas GP, Gadabu OJ, Joukes S, Mumba S, McKay MV, et al. 2010 Using Touchscreen Electronic Medical Record Systems to Support and Monitor National Scale-Up of Antiretroviral Therapy in Malawi. PLoS Med 7(8): e1000319. doi:10.1371/journal.pmed.1000319

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.10003...

sincerely,
Zach Landis Lewis

NLM Pre-doctoral fellow
Department of Biomedical Informatics
University of Pittsburgh

Jose Arindaeng, MD, MPH Replied at 3:16 PM, 5 Oct 2010

I read with interest the post about eHealth monitoring and evaluation. As an end user of various EMR programs, I've seen the limitation of some programs if used a tool for evaluation of quality measures.

Jose Arindaeng, MD, MPH Replied at 3:32 PM, 5 Oct 2010

"This begs the question does health care delivery have additional more complex less understood socio-technical issues than "industries""

Unfortunately or fortunately (depending on which fence you sit)the answer is yes. The practice of medicine is premised on the virtue of compassion. Thus the business of economics were often neglected or added as an afterthought.

A/Prof. Terry HANNAN Moderator Replied at 4:00 PM, 5 Oct 2010

This is a very stimulating discussion. As an 'older' informatician who was guided by original workers in this field (B.Blum/W.Slack/H.Bleich/O.Barnett) and their proteges, Safran, Tierney, Bates, James, Pestotnik, and others we have confirmation that there is an "intimate" (deliberate use of this word) between what we do in direct patient care-make decsions and manage information - and the outcomes related to costs, quality, resource utilisation, etc. So if we can 'measure' these functions of decision support the cost measurements and economic consequences of care can be evaluated.[See concept dictionary ideas]. To add to this we already have evidence that through appropriate decsion support we can measure and improve care. Also these tools allow us to uncover what we did not know and expected which is that not all information management tools are effective. A good example of this is the recent commentary by David Bates on "hard hold" alerts for Adverse Drug Events. As these technologies evolve we will see new ideas and innovations as we uncover what we did not know but have assumed we did. A bit like evolution. In the end the most significant changes will be in the human-technological-information issues.

Om G Replied at 3:09 AM, 6 Oct 2010

The information management decisions made here also guide follow-on technologies.

We have seen how Frontline SMS is being used by the newly emerging Crisis mapping community and the move from Health IT to Politically relevant information use is not a 'leap'.

Health IT have had a big jumpstart and the refinements have been very interesting and almost 'magical' in terms of capability improvements.

On the flipside, hackers who have become interested in humanitarian efforts have made huge strides in recent months developing software that is Open Source and very intriguing.

Health IT might be able to leverage and inform this community to develop still more useful ways to provide and manage care.

One very important aspect that I still maintain, is that the Health community is most likely to provide a basis for building Standards for information exchange.

Ultimately, everything comes down to an individual, in a certain location.

This person needs something and has something to offer.

That is the basis for my work, and the discussion panels here have been a tremendous help. Thank you GHD for allocating resources to provide this innovative Health IT community a home.

Om

om

Steven Wanyee Macharia Replied at 3:24 AM, 6 Oct 2010

Zach, I agree with you that M&E data and patient care data are inevtiably tightly coupled and to extend to you statement, for me, its in the perspective of granularity of that data; you cannot get anymore granular than patient level data. M&E data s guided alot by well developed indicators, but the source of populating those indicators really is the patient level data. I have a very personal interest in M&E for EMRs having spent two lifetimes in both worlds of M&E and EMRs. We are currently developing an electronic M&E system for EMRs and will be glad to share our experience in anyone else interested in that area.

Andrew Kanter, MD MPH Replied at 8:30 AM, 6 Oct 2010

I think my question for the panel would follow-up on Zach, Steve and Jose's comments on using EMRs (patient-level data) for populating M&E and quality indicators. In Africa, there is no other data available most of the time. The paper-based systems are usually rarely used and the quality of the data which is not used at the point of care is very poor. Projects like OpenMRS which we use along with Community Health Worker systems like ChildCount+ (MGV-Net) try to make the data actionable locally... and then can be used for more programmatic and epidemiological functions.

In Uganda, all of the Millennium Village cluster encounters are entered into OpenMRS. We found that nearly 60% of patients who had negative tests for malaria were still be treated. When we instituted an intervention, the number of mistreatments went down by over 50% and we not only saved a substantial amount of money on inappropriate use of medications, but the patients presumably were treated with something that might have helped them. We could not have figured out the problem (fever -> test -> negative result -> treatment with Coartem) if we didn't have row-level data.

Andrew Kanter, MD MPH Replied at 8:57 AM, 7 Oct 2010

So my question is... how do we ensure that we can get this kind of data in resource-poor settings... other than the "8-fold path" described by Dean, in reality, what do we have to do to bring these kinds of patient safety and quality tools down to where they are needed most (a la Zach, Steven and Jose)?

Andrew Kanter, MD MPH Replied at 12:21 PM, 8 Oct 2010

Some comments from Dr. Rodrigues:
1) Applying to the global south solutions successful in the north needs some precautions
It is necessary to check that this will create more good than harm, and for this reason I would recommend insuring quality of care and patient safety by using a reporting procedure based on the Information model developed by WHO and unfortunately called ICPS (for International Classification of Patient Safety) rather than relying on the electronic patient record which is the optimal solution in developed countries.
2) Concerning scalability and sustainability, I would suggest as well to have simple goals... meaning that the overall ICPS information model which is adequately fulfilled by some national or infra national PS reporting systems shall be reviewed to produce a more simple model easier to install and to maintain.
3) Of course this shall not exclude the global south to develop more ambitious program of electronic patient records.

Andrew Kanter, MD MPH Replied at 10:16 AM, 10 Oct 2010

Thanks, everyone! This ends the formal discussion on this topic (global health informatics and patient safety/quality). I will try to summarize and post later, but if our panelists which to make a final statement, I would be happy to include them. Thank you to all contributors (and listeners).

Hamish Fraser, MBChB, MRCP, MSc Moderator Emeritus Replied at 12:00 PM, 10 Oct 2010

I am a bit late to the discussion but have been following it with interest and with Andy’s permission I would like to add some thoughts. Several themes have come through for me in working on health information systems in developing countries over the last decade. Firstly successful projects are very much a result of addressing many key factors, it’s not just about software. Following Dean’s point on the 8 factors I focus on four general categories:

- Leadership support and buy-in. This includes identifying the most important goals and outputs that support improved quality of care, as well as other outputs in program management. Too often the goals of having an EMR are ill defined and driven more by documentation than the use the data is put to. Leadership also needs to set a policy framework and ensure the factors below are addressed.

- Infrastructure. This is clearly essential for electronic data management but can vary enormously even within a resource poor environment. Taking existing EMR projects, at one end you have AMPATH that used OpenMRS in one main site at Moi university, bringing in paper forms and sending them back with printed reports and patient summaries (but are installing local servers now) . At the other is Baobab in Malawi creating a very robust power backup system to ensure that their point of care system runs for 12 hours or more when the clinic power is down. Mobile devices create additional possibilities in sites with poor infrastructure. The important thing is to decide what you have the resources to do and craft realistic processes with a plan B and preferably a plan C…

- Train staff at all levels from data entry staff and data managers to clinicians and leadership. Understanding the value and use of clinical data is crucial. Frequently poor data comes from poor paper documentation rather than transcription errors. We also train developers and IT staff in some sites.

- Software. Last but not least, avoiding complex systems that are high maintenance and ensuring that the focus is on local use of data in clinics and hospitals is key. Studies show (Mate 2009) that if you don’t have good tools and procedures for data collection and management in sites for healthcare delivery then reported data tends to be very poor. OpenMRS (the system that PIH co-developed with the Regenstrief Institute and the South African MRC) is designed to be very flexible so that it can be tailored to local requirements. At the same time it works best when we can actually share the same or similar tools so that we don’t re-invent the wheel. There are only so many useful ways to enter lab data or create patient summaries…

So what does this mean for patient safety? I think that good analysis of the underlying problems and needs in clinical care is crucial. This means identifying the key needs in your sites and at the same time get buy-in from the local staff for the proposed solutions. Try to be very conservative at first in what you do and the data your collect, get some early wins and build on them. Look at what works in developed countries and where there is evaluation data for successful solutions. There is good data now that using a lab reporting systems to improve access to lab data improves healthcare process measures in developing countries, and initial evidence that it improves actual quality of care [Blaya 2010, Amoroso 2010].

Finally a big question for me is how best to address the issue of improving drug prescribing and adverse events. Few projects have direct provider entry of drugs and we need to find efficient ways of capturing that data and getting feedback to the clinicians. We are experimenting with Baobab on direct physician entry of drug orders using touch screens, building on experience with the problem lists. A simple but powerful example was requested by Paul Farmer in 2002 when we built our first HIV-EMR: “Every time an HIV patient has a CD4 count entered that is below 350 and does not have an anti-retroviral regimen entered generate a warning email to the HIV clinical team”. This has proved popular and often generates discussion in the team. Thanks for all the interested comments.

Mate KS, Bennett B, Mphatswe W, Barker P, Rollins N. Challenges for routine health system data management in a large public programme to prevent mother-to-child HIV transmission in South Africa. PLoS One. 2009;4(5):e5483. Epub 2009 May 12.

Blaya J, Fraser HS, Holt B. Evaluations of the Impact of eHealth Technologies in Developing Countries: A Systematic Review. Health Affairs 2010, 29;2: 244-251

Amoroso C, Akimana B, Wise B, Fraser HSF. Using Electronic Medical Records for HIV Care in Rural Rwanda. Stud Health Technol Inform. 2010;160:337-41

Jose Arindaeng, MD, MPH Replied at 2:50 AM, 20 Oct 2010

Great posts. I'm looking forward to Dr. Kanter's summary and report. I'm very anxious to see how we would design the programs and implement these in resource-poor environment.

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