America's health care system has become too complex and costly to continue business as usual. Best Care at Lower Cost explains that inefficiencies, an overwhelming amount of data, and other economic and quality barriers hinder progress in improving health and threaten the nation's economic stability and global competitiveness. According to this report, the knowledge and tools exist to put the health system on the right course to achieve continuous improvement and better quality care at a lower cost.The costs of the system's current inefficiency underscore the urgent need for a systemwide transformation. About 30 percent of health spending in 2009--roughly $750 billion--was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state. This report states that the way health care providers currently train, practice, and learn new information cannot keep pace with the flood of research discoveries and technological advances.About 75 million Americans have more than one chronic condition, requiring coordination among multiple specialists and therapies, which can increase the potential for miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Best Care at Lower Cost emphasizes that a better use of data is a critical element of a continuously improving health system, such as mobile technologies and electronic health records that offer significant potential to capture and share health data better. In order for this to occur, the National Coordinator for Health Information Technology, IT developers, and standard-setting organizations should ensure that these systems are robust and interoperable. Clinicians and care organizations should fully adopt these technologies, and patients should be encouraged to use tools, such as personal health information portals, to actively engage in their care.This book is a call to action that will guide health care providers; administrators; caregivers; policy makers; health professionals; federal, state, and local government agencies; private and public health organizations; and educational institutions.

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

Objective To contextualise the degree of harm that comes from unsafe medical care compared with individual health conditions using the global burden of disease (GBD), a metric to determine how much suffering is caused by individual diseases. Design Analytic modelling of observational studies investigating unsafe medical care in countries’ inpatient care settings, stratified by national income, to identify incidence of seven adverse events for GBD modelling. Observational studies were generated through a comprehensive search of over 16 000 articles written in English after 1976, of which over 4000 were appropriate for full text review. Results The incidence, clinical outcomes, demographics and costs for each of the seven adverse events were collected from each publication when available. We used disability-adjusted life years (DALYs) lost as a standardised metric to measure morbidity and mortality due to specific adverse events. We estimate that there are 421 million hospitalisations in the world annually, and approximately 42.7 million adverse events. These adverse events result in 23 million DALYs lost per year. Approximately two-thirds of all adverse events, and the DALYs lost from them, occurred in lowincome and middle-income countries. Conclusions This study provides early evidence that adverse events due to medical care represent a major source of morbidity and mortality globally. Though suffering related to the lack of access to care in many countries remains, these findings suggest the importance of critically evaluating the quality and safety of the care provided once a person accesses health services. While further refinements of the estimates are needed, these data should be a call to global health policymakers to make patient safety an international priority.

https://qualitysafety.bmj.com/content/qhc/22/10/809.full.pdf

The global burden of unsafe medical care: analytic modelling of observational studies

https://www.medpagetoday.com/upload/2013/2/22/amiajnl-2012-001241.full.pdf

Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems.

The Health Information Technology for Economic and Clinical Health (HITECH) Act subsidizes implementation by hospitals of electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries caused by medication errors (preventable adverse drug events, pADEs). Effects on pADEs have not been rigorously quantified, and effects on medication errors have been variable. The objectives of this analysis were to assess the effectiveness of CPOE at reducing pADEs in hospital-related settings, and examine reasons for heterogeneous effects on medication errors. Articles were identified using MEDLINE, Cochrane Library, Econlit, web-based databases, and bibliographies of previous systematic reviews (September 2013). Eligible studies compared CPOE with paper-order entry in acute care hospitals, and examined diverse pADEs or medication errors. Studies on children or with limited event-detection methods were excluded. Two investigators extracted data on events and factors potentially associated with effectiveness. We used random effects models to pool data. Sixteen studies addressing medication errors met pooling criteria; six also addressed pADEs. Thirteen studies used pre-post designs. Compared with paper-order entry, CPOE was associated with half as many pADEs (pooled risk ratio (RR) = 0.47, 95% CI 0.31 to 0.71) and medication errors (RR = 0.46, 95% CI 0.35 to 0.60). Regarding reasons for heterogeneous effects on medication errors, five intervention factors and two contextual factors were sufficiently reported to support subgroup analyses or meta-regression. Differences between commercial versus homegrown systems, presence and sophistication of clinical decision support, hospital-wide versus limited implementation, and US versus non-US studies were not significant, nor was timing of publication. Higher baseline rates of medication errors predicted greater reductions (P < 0.001). Other context and implementation variables were seldom reported. In hospital-related settings, implementing CPOE is associated with a greater than 50% decline in pADEs, although the studies used weak designs. Decreases in medication errors are similar and robust to variations in important aspects of intervention design and context. This suggests that CPOE implementation, as subsidized under the HITECH Act, may benefit public health. More detailed reporting of the context and process of implementation could shed light on factors associated with greater effectiveness.

https://link.springer.com/content/pdf/10.1186%2F2046-4053-3-56.pdf

The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis

As research laboratories and clinics collaborate to achieve precision medicine, both communities are required to understand mandated electronic health/medical record (EHR/EMR) initiatives that will be fully implemented in all clinics in the United States by 2015. Stakeholders will need to evaluate current record keeping practices and optimize and standardize methodologies to capture nearly all information in digital format. Collaborative efforts from academic and industry sectors are crucial to achieving higher efficacy in patient care while minimizing costs. Currently existing digitized data and information are present in multiple formats and are largely unstructured. In the absence of a universally accepted management system, departments and institutions continue to generate silos of information. As a result, invaluable and newly discovered knowledge is difficult to access. To accelerate biomedical research and reduce healthcare costs, clinical and bioinformatics systems must employ common data elements to create structured annotation forms enabling laboratories and clinics to capture sharable data in real time. Conversion of these datasets to knowable information should be a routine institutionalized process. New scientific knowledge and clinical discoveries can be shared via integrated knowledge environments defined by flexible data models and extensive use of standards, ontologies, vocabularies, and thesauri. In the clinical setting, aggregated knowledge must be displayed in user-friendly formats so that physicians, non-technical laboratory personnel, nurses, data/research coordinators, and end-users can enter data, access information, and understand the output. The effort to connect astronomical numbers of data points, including ‘-omics’-based molecular data, individual genome sequences, experimental data, patient clinical phenotypes, and follow-up data is a monumental task. Roadblocks to this vision of integration and interoperability include ethical, legal, and logistical concerns. Ensuring data security and protection of patient rights while simultaneously facilitating standardization is paramount to maintaining public support. The capabilities of supercomputing need to be applied strategically. A standardized, methodological implementation must be applied to developed artificial intelligence systems with the ability to integrate data and information into clinically relevant knowledge. Ultimately, the integration of bioinformatics and clinical data in a clinical decision support system promises precision medicine and cost effective and personalized patient care.

/pdf/clinical-decision-support-systems-for-improving-diagnostic-xzmfxrkzhz.pdf

Clinical decision support systems for improving diagnostic accuracy and achieving precision medicine.

With interest we have read the article by Villamanan et al. [1]. They stated that medication errors (MEs) occur commonly in hospitals, and emphasized that while most such MEs have little potential for harm, they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events (ADE). It is written that ADEs ‘‘have a major impact on the healthcare system. Several studies over the last few years have shown that they are largely due to failures during the ordering stage of the medication process. About one-third of serious MEs occur in this phase’’ [1]. It is then argued that MEs have resulted in patient deaths each year, and can also cause adverse reactions that range from the minor occasions to major disabilities. Computerized Physician Order Entry (CPOE) is established to ensure that patients do not receive medication that is wrong or dangerous for them. MEs occur in the process of ordering, dispensing, or administering a medication at the wrong time or not at all, regardless of whether an injury occurred or whether the potential for injury was present. Two years ago, a survey was conducted by Kazemi et al. [2] that showed most of the MEs happen at the prescribing stage, and the most common type is dose error. ADEs occur three times more often in newborns than in adults. Result of this Iranian study show that ‘‘Drug dose related errors are usually the most frequent when clinicians prescribe treatments manually’’ [2]. They argue that ‘‘Research in Iran showed dose errors were more often intercepted than frequency errors. Over-dose was the most frequent type of MEs, and curtailed-interval was the least’’ [2]. It is concluded that the neonatal ward CPOE without decision support functionality neither reduces non-intercepted dose, nor frequency of MEs for antibiotics and for anticonvulsants. However, when paired with a dose decision support system, CPOE is capable of reducing these errors. The effects of CPOE on medication errors are also demonstrated in this research, and this is done according to different specialties. However, the new study fails to show the effect of CPOE according to either types of hospitals (public, private, non-profit) or where they are located (metropolis, urban or rural). It therefore could be concluded that use of CPOE minimizes the occurrence of MEs, however, they still occur. Most errors are associated with the CPOE technology. The health industry therefore faces a new challenge in the prevention of ME that require a change in strategy for patient safety. Processing a prescription drug order through a CPOE system decreases the likelihood of errors [3]. Systems such as these have the potential to both fix and cause problems, and require evaluation. As one of us coauthored elsewhere [4] on this matter, the reductions occurred because order entry both structured orders and facilitated the checking of them. Further reductions should be possible with additional decision support. Such refined systems should therefore be used more widely.

Sadun Khezri

Papers

The impact of computerized physician order entry on medication error prevention.