Presentation Transcript
The Impact of Technology on Quality of Care Joel J. Nobel, MD Founder & President Emeritus ECRI: The Impact of Technology on Quality of Care Joel J. Nobel, MD Founder & President Emeritus ECRI
Healthcare Technology Comprises: Healthcare Technology Comprises Drugs
Biotechnologies
Devices
Medical Procedures
Surgical Procedures
Technology: A Two-edged Sword: Technology: A Two-edged Sword Most medical advancements of the past century are based on technology
But technology is the primary driver of escalating healthcare costs, complexity & current challenges to safety and quality
Forge Another Two-edged Sword: Forge Another Two-edged Sword The usual response to technology induced adverse effects is to introduce compensating new technologies, specialized personnel & rules
This response usually introduces new complexities, costs & challenges but only partially responds to the self-generated problem
Response Modes: Response Modes Usually complexity and costs are compounded
Sometimes the health community responds by invoking the technologic equivalent of zero-based budgeting – eliminating the original technology.
Historical Example: Ether and Cyclopropane Anesthetics: Historical Example: Ether and Cyclopropane Anesthetics Problem: Both anesthetics are explosive & occasional explosions were triggered by static electrical discharges
Adverse impact: Injuries, deaths & physical damage
Response: Anti-static conductive floors, furniture, footwear and isolation transformers etc. i.e. more technology & costs
Historical Example: Anesthetics (2): Historical Example: Anesthetics (2) Compounded complexity:
Mandatory footwear conductivity tests before entering surgical suite & periodic tests of floor and furniture conductivity
Mandatory tests of isolation transformers
Purchase of specialized test equipment
Associated record keeping
Associated staff training
Historical Example: Anesthetics (3): Historical Example: Anesthetics (3) Secondary Adverse Effects caused by safety technology
Conductivity increased incidence of electric shock and aberrant surgical diathermy return paths with attendant radio-frequency burns to patients and staff
Isolation transformers limited ampacity and circuit overloads tripped breakers & their associated line isolation monitors caused ECG artifacts
Historical Example: Anesthetics (4): Historical Example: Anesthetics (4) Despite precautions occasional explosions still occurred
Electric shock & surgical diathermy burns also required investigation & resolution, which, in turn, required more specialized personnel and test equipment
Insurance companies, manufacturers, attorneys & courts became involved.
Historical Example: Anesthetics (5): Historical Example: Anesthetics (5) Anesthetics, developed to diminish pain, had the peculiar effect of transmuting physical pain to psychological pain & transferring that pain from patients to hospital staff.
Historical Example: Anesthetics (6): Historical Example: Anesthetics (6) The Answer? Zero-based technology change
Replacement of explosive ether & cyclopropane with non-explosive halogenated anesthetics which allowed elimination of anti-static measures e.g. conductive floors, furniture, footwear, testing devices & isolation transformers & associated record keeping and training
Current Example: Drug Errors: Current Example: Drug Errors Problem: Medication errors have been identified as a significant risk to patients and physician handwriting as a major culprit.
Proposed solution: Computerized Prescriber Order Entry Systems (CPOE)
Current Example: Drug Errors (2): Current Example: Drug Errors (2) CPOE systems can be beneficial if integrated with a comprehensive electronic patient record & pharmacy management systems (blocking orders of incompatible drugs, doses inappropriate to the size and age of the patient, known drug allergies, etc.)
Current Example: Drug Errors (3): Current Example: Drug Errors (3) BUT:
What is the top cause of prescription errors? Is it physician handwriting? NO! Illegible and unclear handwriting accounts for only 2.9% of medication errors but keyboarding errors cause 13% of reported medication errors!
Current Example: Drug Errors (4): Current Example: Drug Errors (4) WORSE: Computer users prescribing drugs who had the required knowledge to use the computer erred in execution in 38.2% of the drug errors and users lacking knowledge of computer functionality were responsible for 11.3% of drug errors
Current Example: Drug Errors (5): Current Example: Drug Errors (5) Conclusions:
13+38.2+11.3=59.5% of 235,000 drug error reports to USP from 570 healthcare facilities implicate use of computers
More knowledgeable computer users erred more often than less knowledgeable users
Training seems to make things worse
The solution is now the problem
Nobel’s Law: Nobel’s Law Nobel’s law is also known as the law of conservation of trouble and was first introduced in 1973 at Senate Health Subcommittee hearings on proposed medical device legislation. It states that “Trouble is incompressible. Squeeze it here and it oozes out there – usually in a different form and often in greater amount”
Bedrails: A Case Study in the Immutability of Nobel’s Law: Bedrails: A Case Study in the Immutability of Nobel’s Law Premise: Allowing patients to fall out of bed and fracture their hips or skulls is poor quality of care. Patients usually climb out of bed to go to toilet because there is no nurse available to assist them
Technological response: Bed rails to prevent falls
Patient response: I have to go to the toilet, the nurse doesn’t come to help when I push the call button. I’ll try to climb over this rail
Consequence: Patient falls further with greater injury
Proper approach: More nursing staff to respond faster, especially at night.
Bedrails (2): Bedrails (2) Conclusions:
Bedrails cannot substitute for nurses
A groggy sedated patient with a full bladder cannot be denied
Rapid responses to nurse call buttons 24X7 are one measure of quality of care, both in terms of patient perception & reality
Quality of nursing care, not technology, is the primary factor in patient and family perception of quality of care
Technology Impact on Quality of Care: Technology Impact on Quality of Care Overstating the case with the prior examples is a warning to think things through carefully, test before implementation and evaluate continuously, not to condemn technology. Obviously modern medical care, with its great improvement in life-spans, reduction in disability, prevention of disease & control of pain is predicated on the use of technology
Technology Impact on Quality of Care (2): Technology Impact on Quality of Care (2) Endoscopy versus open procedures
MRI angiography versus cardiac catheterization for coronary artery visualization
Virtual colonoscopy
Technology Impact on Quality of Care (3): Technology Impact on Quality of Care (3) Diversion of financial resources: e.g. more machines or more nurses?
Diversion of training resources: e.g. electrical safety versus preventing falls from beds
Diversion of attention from thoughtful priorities to less productive alternatives.
Technology Impact on Quality of Care: (4) - Judging the Value of Technologies: Technology Impact on Quality of Care: (4) - Judging the Value of Technologies Determining core values and objectives
Determining priorities
Technology assessment, its virtues and limitations
Classical Core Values & Objectives: Classical Core Values & Objectives Prevent significant disease
Diminish death and disability
Postpone death when it is meaningful to do so
Priorities: Priorities Public versus private good
Public versus private healthcare systems
Reimbursement systems
Distortion of priorities by competition
Impact on choice of technologies and quality of care
Technology Assessment: Virtues & Limitations: Technology Assessment: Virtues & Limitations Conflict between experience and scientific proof
Conflict between hope, belief and reality
Data limitations
Temporal limitations
Information resources
Quality of Care: Quality of Care Technology value: perception versus measurement
Quality of care: perception versus measurement
Bringing it all together