Transcript No Slide Title

Improving Communication Between
Healthcare Providers Outside and
Within Hadassah: Use of Academic
Detailing to Overcome Barriers
Presentation to Hadassah Board Quality Committee
January 11, 2012
Alyssa Hochberg, BSc
Meir Frankel, MD
Lois Gordon, MPH
Mayer Brezis, MD MPH
Center for Clinical Quality & Safety
Hadassah Hebrew University Medical Center
2010 Project:
Survey of 100 patients hospitalized while
taking 5 or more medications
Chaos Waiting for Bad Luck?
Medication Reconciliation Should Be Mandatory
Roni Cohen, B.Sc., Inbal Yifrach-Damari, M.Sc.*
In 97%, there
was
error
in the
Dr.
Meiran
Frankel,
Prof. Mayer
Brezisprescription in
hospital or at discharge
Hadassah-Hebrew University Hospital, Jerusalem, Israel
On average: 3 errors per patient
1%* Clinical
potentially
life-threatening
Pharmacist, Pharmacy
Division
student, School of Pharmacy, Hebrew University
MedicationPharm-D
Continue
Discontinue
Start
Why?
Aspirin

Furosemide

Hypokalemia
Cefuroxime With Help From Joint Commission International

Pneumonia
Medication Errors
 Medication errors are the fourth leading cause of
death or major permanent loss of function in hospital
patients.
 The majority of problems with patient safety occur
during the transition from one care setting to another.
 Ambulatory-hospital lack of communication is
responsible for 50% of medical errors.
Medication Errors: We Are Not Alone…
The Challenge of Improving
Transition of Care
Hospital
Quality
of
Transition
Community
Quality of
Cycle of Care
Continuity of Care
Transition of Care: A Widespread Issue
Presentation to Hadassah Board Quality Committee
January 11, 2012
Alyssa Hochberg, Lois Gordon,
Dr. Meir Frankel, Prof. Mayer Brezis
Hadassah Center for Clinical Quality and Safety
Hebrew University of Jerusalem
Introduction


Follow-up care is a weak link in the chain of
quality of patient care, and lack of accuracy in
information transfer between caregivers, in the
community and in hospitals, can result in errors
that can be life-threatening.
Attempts to implement communication via
computerized systems between health funds
and hospitals have encountered technical and
logistical problems, as well as a lack of
cooperation on the part of physicians.
Introduction


For example: during the past two years, a
computerized communications system has
been established between Hadassah and the
Maccabi and Meuhedet Health Services.
Via this system, hospital-based doctors can
obtain information on the diagnoses, blood
tests and routine medications of their
hospitalized patients.
Introduction



Notification has been sent to medical staff working
with these communication systems, but its use has
been limited.
Attempts by Meuhedet to create similar computerized
systems in a number of their emergency facilities in
Israel have met with a similar fate.
In order to implement the use of such computerized
systems, keeping in mind the limitations that have
prevented their widespread use, a decision was made
to use ACADEMIC DETAILING as a tool.
Introduction
Academic Detailing
Introduction
Academic Detailing



The “educator” for this method of academic detailing
is a professional, such as a pharmacist, nurse, doctor
or medical student, who acts as a promoter for the
improvement of patient care.
This educational method is based on medical facts,
supports patient safety, takes into account costeffectiveness, and is directed towards improving the
quality of medical care.
A key component of academic detailing is its financial
independence from the pharmaceutical industry!
Introduction
Academic Detailing


Academic detailing is comprised of education
through academic promotion directed towards
physicians in emergency rooms.
Research has shown that this method is practical,
efficient and safe, particularly when combined with
process supervision and appropriate feedback from
the medical staff. It is an excellent means of
implementing specific positive behavior patterns
among hospital staff.
Introduction:
Academic Detailing
This method, introduced by Jerry Avorn (Harvard),
Avorn and Soumerai. Improving drug-therapy decisions through educational outreach — A
randomized controlled trial of academically based detailing. N Engl J Med 1983; 308:1457-1463
Avorn and Soumerai. Principles of educational outreach ('academic detailing') to improve clinical
decision making JAMA. 1990;263:549-556
has succeeded in effecting changes such as:
‣ Reducing overuse of wide-spectrum antibiotics
Solomon D.H. et al, Academic detailing to improve use of broad-spectrum antibiotics at an
academic medical center. Arch Intern Med 161;2001;1897-1902
‣ Reducing overuse of antidepressants for elderly
van Eijk M.E.C. et al, Reducing prescribing of highly anticholinergic antidepressants for elderly
people: randomised trial of group versus individual academic detailing. BMJ 322;2001;1-6.
‣ Reducing medication errors
Wortman S.B., Medication reconciliation in a community, nonteaching hospital. Am J HealthSyst Pharm 65;2008;2047-2054
Intervention Program Using
Academic Detailing
Computerized Communication Between
Hadassah & the Community


In January 2011, a cooperative effort between Hadassah
and the Meuhedet Health Services began. A
computerized system was set up for obtaining
information on patients arriving at the emergency room
or hospitalized at Hadassah.
With the establishment of the system, notification was
sent to all hospital staff. However, over a four-month
period, use of this computerized system remained
marginal.
Computerized Communication Between
Hadassah & the Community

Since 2009, there has been similar cooperation between
Hadassah and the Maccabi Health Services. A
computerized communications system was established to
enable receipt of information on Maccabi patients
hospitalized at Hadassah. Use of this system was also
very marginal.
Implementing the Use of Computerized
Communication Systems:
The Intervention Program

The use of academic detailing: this method is

In practice: promotional activity on the part of a
comprised of education through academic
promotion directed towards physicians in
emergency rooms.
medical student, directed towards doctors in the
emergency rooms of Ein Kerem and Mount Scopus
hospitals included: general explanation of the
system, advantages, and individualized
demonstrations geared towards helping ER doctors
use the program effectively.
Implementing the Use of Computerized
Communication Systems:
The Intervention Program
The intervention included:

Speaking to doctors individually

Evaluating their familiarity with the system

Understanding their attitude towards using the system:
advantages, barriers to use and suggestions for
improvement
‣ Printing additional information from the system
and adding it to patient files with a sticker to flag
the information obtained from the system


Posting informational signs
near the computer stations at
the hospital, to encourage use
of the system
Sending an e-mail to all
hospital physicians about the
computerized program
Implementing the Use of Computerized
Communication Systems:
Methods



Data gathering is comprised of both quantitative
and qualitative aspects.
Quantitative research: evaluating the change in the
proportion of entries into the system before,
during and after the intervention (prospective
study).
Qualitative research: based on the responses of the
doctors themselves and serves as a means of
understanding the advantages and disadvantages
of the system, barriers to its use and suggestions
for improvement.
Preliminary Results
From a quantitative perspective, an
initial analysis indicates that a
significant increase in the number of
system entries has been observed,
close to and following the
intervention, as indicated in the
following graph…
600
500
Number of computer entries
email &
outpatient
clinics
intervention:
academic detailing
E
I
signs & email
N
400
communication
system with
Meuhedet
300
K
E
200
R
E
100
M
0
Feb
ER
visits
2011:
Ein
Kerem
March April
May
June
Maccabi
Feb
Mar
July
Aug
Meuhedet
Sept
Oct
Nov
Dec
Total
Apr
May
June
July
Aug
Sept
Oct
Nov
5985
6449
6421
6599
6295
6181
6211
5832
Dec
600
MOUNT SCOPUS
Number of computer entries
500
email &
outpatient
clinics
400
300
intervention:
academic detailing
200
signs
e-mail
100
0
April
May
June
July
Maccabi
ER
visits
2011:
Mt.
Scopus
Aug
Meuhedet
Sept
Oct
Nov
Dec
Total
Apr
May
June
July
Aug
Sept
Oct
Nov
4628
5047
4990
5224
4964
5004
4877
4414
Dec
Qualitative Results
During the initial individual meetings of the
medical student with 97 doctors, it became
clear that:
‣ 51% do not use the computerized program in the
emergency room
‣ 14% have used it once or twice
‣ 24% have used it several times
‣ 10% have used it only “when relevant” (without
specifying the number of times)
‣ 27% did not know about the existence of the system
Qualitative Results



47% of the doctors received a complete
explanation of the program and its link to
health fund records
37% of the doctors witnessed a demonstration
of the program
35% of the doctors thought that they would
use the program after receiving an
explanation/demonstration.
Important Observations Made by
the Doctors Approached



Positive reactions: great idea, technically simple, works
beautifully in the ER
Significance of the system: identifies medication given
or auxiliary tests performed at health fund facilities;
useful when there is lack of information (regarding
creatinine levels or previous ECG); “very useful” and
improves patient care
Barriers encountered: “there’s enough information from
other sources”; “we’re not used to using the system”;
“don’t use system because of time constraints in the
ER”; “we didn’t manage to access the system from the
ER”; “the link is not user-friendly.”
Important Observations Made by
the Doctors Approached
Suggestions for improvement:
‣ Updating and organization of patient medications
in the system
‣ Automatic copy/paste of information from health
service records into Hadassah’s computer system
‣ Allow entry into the system from outpatient clinic
computers
‣ Allow entry into the system for clinical
pharmacologists and nurses
‣ In addition, many doctors emphasized the need for
access to Clalit Health Services records
Limitations of the Study
 Research
still lacks a long-term perspective
 Change
in quality of care as a result of an increase in
system usage was not examined. However, an Israeli
study conducted in 2010 indicated that use of a
computerized communications system with Clalit
Health services reduced the number of radiological
examinations and was linked to improvement in
certain select quality parameters.*
 Some
doctors refuse to even be informed about the
system/use it (although they were a minority).
*Nirel N. et al, OFEK virtual medical records: an evaluation of an integrated
hospital-community system. Harefua 2011 Feb;150(2):72-8, 209.
Conclusions



Current results indicate that this intervention
resulted in increased use of the computerized
system, raised suggestions regarding improvement,
and helped in understanding doctors’ attitudes
towards using the system.
Technology benefits from promoting appropriate
usage!
Academic detailing is an interesting and promising
method for understanding barriers, changing
behavior of hospital-based clinicians and
implementing a new and useful computerized tool
that can greatly assist doctors.
Acknowledgments



Dr. Rosenblum and staff, Department of Information
Systems, Meuhedet Health Services
Prof. Yosef Karako and staff, Department of Information
Systems, Macabbi Health Services
Ms. Efrat Simon and staff, Department of Information
Systems, Hadassah Medical Center

Dr. Kobi Assaf and staff, ER Hadassah Ein Kerem

Dr. Stalnikovich and staff, ER Hadassah Mount Scopus
Further Steps
1. Extend “IT connectivity” to other sick funds (Clalit & Leumit)
2. Continue monitoring use; boost academic detailing as needed
3. Introduce formal medication reconciliation at all transitions
Medication
Continue
Aspirin
Furosemide
Cefuroxime

Discontinue

Start
Why?

Hypokalemia
Pneumonia
4. Develop other “transition-of-care tools” to improve the routine
teamwork among departments
5. Recheck error rates
Between Hospital and Community:
More Than Just Medications…
Some
speciality
clinics
X-rays
Many
speciality
clinics
CT, US
Hemodialysis
Primary
physician
Breast cancer
screening
(mammography,
biopsy, etc.)
Hospital
Radiology (CT, US, MRI)
Gastro/Colonoscopy
Expert consultation
Day care
Echo, Holter
Bronchoscopy
Hemodialysis
Surgery
Angiography
Multi-disciplinary clinics (diabetes, breast, etc.)
Endoscopy,
Bronchoscopy
Simple
lab tests
Hightechnology
labs
Multidisciplinary
clinics
Day care
Hematology
Heart failure
Simple
surgeries
Ophthalmology
Plastic surgery
etc.
Handoffs in Hospitals:
Source of Concern in the Literature
Intra-hospital Transitions
ER
Department A
Department
Department B
Department
ICU
Department
OR
OR
ICU
Department
Department
Institutes (Cardiology,
Gastroenterology, Pulmonology,
Invasive Radiology etc.)
Hemodialysis