Impact of Healthcare Techology on Quality Care

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Information about Impact of Healthcare Techology on Quality Care
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Published on October 15, 2007

Author: FunnyGuy

Source: authorstream.com

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

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