Transcript Improving patient safety using GP computer systems

Developing e-health solutions to improve
patient safety in primary care
Report on an NPSA-funded project
Professor Tony Avery
University of Nottingham
Background
• There are concerns about patient safety in
primary care in terms of:
 Prescribing errors
 Failure to complete intended actions such as
patient referrals and medication monitoring
 Failure to respond to abnormal results or advice
from other professionals
 Safe and effective communication of information
between GPs and patients and professionals in
secondary care and community pharmacy
Potential role of computer systems
• Computers have considerable potential to help
GPs to practise safely in terms of providing:
– Accurate information on patients and drugs at the
point of decision-making
– Effective decision support
– Intelligent hazard alerts for cautions,
contraindications, drug interactions and allergies
– Help with timely and appropriate monitoring
– Help with error trapping
– Reporting on patients at risk
Why the need for a project?
• While computer systems have
considerable potential some problems
have been highlighted:
– GPs and practice staff may not know how to
make best use of their systems and may not
use important safety features
– GPs may override hazard alerts
– Computer systems may not contain all the
safety features that are desirable
Objectives of the project
• To identify the most important safety issues
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regarding GP computer systems
To assess GP computer systems in terms of
these safety features
To determine GPs’ knowledge, use and
training needs in relation to computerised
safety features
To work with stakeholders to produce
specifications for GP computer suppliers and
for training practice staff
Identifying the most important
safety issues
• Methods used:
– Stakeholder interviews
– Two-round Delphi
Stakeholder interviews
• GPs
• Computer system
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suppliers
Drug database
suppliers
SCHIN
RCGP
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DoH
NHSIA
Design Authority
MDU and MPS
Patients’
representative
Experts in health
informatics
The Delphi exercise
• 21 participants
• Presented with 55 statements
• 33 statements ranked as important or very
important by over 90% of respondents
Key issues from Delphi and
stakeholder interviews
• Importance of computerised alerts
• The need to ensure that users record data so that functionality is
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available when required
The need for a drug dictionary for NHS primary care
The need for drug ontologies that provide sensible alerts and decision
support
Avoiding spurious alerts
Making it difficult to override critical alerts and to have audit trails
Effective computer-user interface: ensuring that account is taken of
human ergonomics
Support for safe repeat prescribing
Importance of call and recall: ensuring that intended actions such as
patient referrals and medication monitoring are completed
Need to be able to run “safety reports”
Assessing GP computer systems
• From the results of the Delphi we have
developed a series of vignettes/test
cases
• These have been used on the main GP
computer systems with dummy patients
• Suppliers were asked to comment on
the results
• Results available on www.bmj.com
BMJ 2004;328:1171-1172
Key points from assessment of GP
computer systems
• There are a lot of good features, but we have
detected some problems:
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Lack of alerts in relation to contraindications
Spurious alerts
Failures of drug allergy warnings
Risks of prescribing drugs with similar names
Lack of warning for methotrexate
“Hidden” alerts
It is easy to override most alerts
Lack of audit trials
Determining GPs’ knowledge,
use and training needs
• We have undertaken interviews with GPs:
– There was a strong sense that they have come to
rely on their computers to provide alerts
• We have developed a questionnaire that has
been sent to GPs in two sites in England (387
responses; 64% response rate)
Key findings from the
GP questionnaire (1)
• The following are regarded as important
by >90% of GPs
– computerised alerts
• Allergy alerts (99%)
• Interaction alerts (99%)
• Contraindication alerts (99%)
– Need to make it more difficult to override
critical alerts
– Systems for recall for patient monitoring
Key findings from GP
questionnaire (2)
• GPs are not fully aware of the safety features on
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their computer systems, e.g. a third of users of
a system that doesn’t have contraindication
alerts thought that the system did have these
alerts!
Only a minority have had training on the use of
safety features on their computers
The preferred method for learning more about
the use of safety features is “hands-on” learning
with tuition (either one-to-one or in a group
setting)
Stakeholder’s views on how to
make improvements to systems
• System suppliers are willing to make changes
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provided these are sensible and in keeping with
GP opinion
Suppliers acknowledge that change is more
likely to take place if this is made mandatory
rather than voluntary
Working through the National Programme for IT
in the NHS is likely to be the best way of
ensuring change
Suggestions for improvement in the
short-term
• Act to close the loophole in the recording of allergy alerts
• Define the most important hazard alerts, ensure these are
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available on all systems and that they cannot easily be
overridden
Ensure that system suppliers make full use of ontologies
available to them, e.g. for contraindication alerts
Develop a computerised “query set” for interrogating GP
computer systems to identify hazards
Develop a training package to help practices make best use of
the safety features of their clinical computer systems
Suggestions for improvement in the
longer-term
• Introduce a drug dictionary for the NHS
• Evaluate existing ontologies to determine whether these
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are fit-for-purpose or whether alternatives need to be
developed
Ensure that systems are designed to “make it easy to do
the right thing”
Ensure that the design of alert messages take account of
research indicating best practice
Ensure that health professionals are properly trained to
make best use their systems
Work to develop safety culture in primary care
Summary
• GP computer systems already have a number of
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important safety features
There are problems in that
– GPs have come to rely on hazard alerts when they are not
full-proof
– GPs do not know how to make best use of safety features on
their systems
• There are a number of solutions that could either
– Help to improve the safety features of GP computer systems
– Help to improve the abilities of healthcare professionals to
use these safety features