Doctors need to stay current on 10,000 diseases, 3,000 medications, 1,100 lab tests and 400,000 articles added to the biomedical literature each year. Sounds like a job for the field of knowledge management. This excerpt outlines how Partners HealthCare in Boston attempts to keep doctors up to date by "embedding" knowledge in technology doctors use everyday.
Embedding knowledge into everyday work processes is time-consuming and expensive. It's not an undertaking that anyone in his right mind would tackle without a very good reason. A decade ago, Partners had that reason: Researchers at the Harvard School of Public Health and Harvard Medical School found that there were surprisingly high numbers of medical errors and adverse drug reactions at Partners hospitals. That these institutions could be unconsciously acting in direct opposition to their healing mission was deeply troubling.
Under the direction of H. Richard Nesson, CEO of Brigham and Women's at the time, Partners undertook an ambitious and risky project to link massive amounts of constantly updated clinical knowledge to the IT systems that supported doctors' work processes. The project was ambitious because it had the potential to substantially improve the quality of physicians' decision makingand hence improve the quality of patient care. But it was also risky because knowledge-based systems had a very spotty record of success in their first incarnation two decades ago and because Partners didn't really know if it would be able to codify the millions of facts and data points that doctors use to make complex decisions about treatment.
|Partners' approach is built on a set of integrated information systems including on-line referral and medical-records systemsthat physicians can use to manage patient care.|
| Thomas H. Davenport and John Glaser|
So the project was defined relatively narrowly at first. Partners professionals targeted an essential work processphysician order entryand a problem that was well documentederrors in drug prescriptions and lab-test ordering. Drug interactions are relatively straightforward and easy to program; this fact, too, improved the project's chances for success.
The decision to focus on the order-entry system was important because the system is central to physicians delivering good medical care. When doctors order tests, medications, or other forms of treatment, they're translating their judgments into actions. This is the moment when outside knowledge is most valuable. Without the system, doctors would have no easy way to access others' knowledge in real time. Automated order entry addresses this need in several ways: It increases efficiency and safeguards against errors due to poorly written orders. Even more important, it allows physicians easy access to massive amounts of up-to-date medical knowledge while they go about their daily work. Indeed, the order-entry system forces physicians to engage with queries or recommendations (although, as we shall see, they can always override the system's recommendations).
Tying it all together
Order entry is a key work process in this system, but it's not the only one. Partners' approach is built on a set of integrated information systemsincluding on-line referral and medical-records systemsthat physicians can use to manage patient care. These all draw from a single database of clinical information and use a common logic engine that runs physicians' orders through a series of checks and decision rules.
Here's how it works. Let's say Dr. Bob Goldszer, associate chief medical officer and head of the Special Services Department at Brigham and Women's in Boston, has a patient, Mrs. Johnson, and she has a serious infection. He decides to treat the infection with ampicillin. As he logs on to the computer to order the drug, the system automatically checks her medical records for allergic reactions to any medications. She's never taken that particular medication, but she once had an allergic reaction to penicillin, a drug chemically similar to ampicillin. The computer brings that reaction to Goldszer's attention and asks if he wants to continue with the order. He asks the system what the allergic reaction was. It could have been something relatively minor, like a rash, or major, like going into shock. Mrs. Johnson's reaction was a rash. Goldszer decides to override the computer's recommendation and prescribe the original medication, judging that the positive benefit from the prescription outweighs the negative effects of a relatively minor and treatable rash. The system lets him do that, but it requires him to give a reason for overriding its recommendation.
The fact that the order-entry system is linked not just with the clinical database but also with the patient's records increases its usefulness by an order of magnitude. The system may inform Goldszer that a drug being prescribed is not economical or effective, but it can also tell him that the patient is taking another drug that interacts badly with the new medication or one that might exacerbate a condition other than the one being treated. When it comes to ordering tests for a patient, the system may note that a particular test is generally not useful in addressing the symptoms identified or that it has been performed on the patient enough times that a retest would not be useful.
That's a relatively simple explanation of what the integrated system does, but, in fact, the logic engine and the knowledge base can serve as very sophisticated screens for the physicians' decisions. For instance, imagine that a patient with a history of sleep apnea is prescribed a narcotic to mitigate pain after surgery. Narcotics can cause people with sleep apnea to go into respiratory arrest, but, as long as the history of sleep apnea is noted in the patient's medical records, the system will alert the physician to that potential problem. It also takes into account the patient's age, likely metabolism, probability of renal failure, maximum allowable lifetime amounts of a chemotherapy agent, and hundreds of other factors.
The logic engine and knowledge base at Partners are used more during order entry than at any other time. But they are used increasingly during normal review of patient medical records as well. For example, the system alerts the physician, as he or she reviews Mrs. Smith's record, to follow up on her marginally abnormal mammogram or to recheck her cholesterol levels. In addition, it may remind a physician that a particular patient should receive a call or schedule a follow-up appointment.
Alert system built in
There are, of course, times when a physician isn't treating a patient directly yet still needs to know that something has happened. For these times, Partners developed an event-detection system that alerts a physician when a hospitalized patient's monitored health indicators depart significantly from what is expected. The physician is notified through a pager and can then visit the patient directly or call in a new treatment. Minor variations are routed to the nurses' station, and the nurse can decide whether to call in the physician.
|A controlled study of the system's impact on medication errors found that serious errors were reduced by 55 percent.|
| Thomas H. Davenport and John Glaser|
The power of knowledge-based order-entry, referral, computerized medical-record, and event-detection systems is that they operate in real time. Knowledge is brought to bear immediately without the physician having to seek it out. In some situations, physicians can consult with other experts in real time, via teleconferencing and other technologies. Such practices are still in their early stages, but they show great promise. For example, if a patient on Nantucket island experiences what his doctor suspects is a stroke, he needs to be diagnosed and treated within an hour or his chances for full recovery drop precipitously. By the time he is flown to Cape Cod Hospital, it might be too late. If a specialist in Boston, or for that matter in Tel Aviv, can interview the patient over a videoconference screen, observe how he speaks and moves, and review scan results, the likelihood of effective treatment will go way up.
Partners has also assembled many other knowledge resources that are not accessible in real time but are valuable nonetheless. These sources are more extensive than what is in the clinical-information database. However, they're like traditional knowledge-management systems in that users need to seek them out. The organization's on-line sources (collectively called The Handbook) include online journals and databases, care protocols or guidelines for particular diseases, interpretive digests prepared by Partners physicians, formularies of approved drugs and details on their use, and even on-line textbooks. All of these resources are accessible through an integrated intranet portal. It's an unusually good set of resources, but they're not different in kind from those that practitioners at other hospitals can consult. The Handbook is accessed, across all Partners institutions, about 3,000 times a day. Contrast this with the 13,000 orders submitted a day at Brigham and Women's alone; even though it's invisible to the clinicians, the information embedded in the order-entry system is used far more intensively than The Handbook is.
While Partners' embedded-knowledge program has been under development for more than a decade, it's still not complete. The on-line order-entry system and related knowledge are only accessible within the organization's two flagship hospitals, Mass General and Brigham and Women's. Medical knowledge has not yet been codified for all the diseases that Partners physicians treat. But the approach is clearly beneficial. A controlled study of the system's impact on medication errors found that serious errors were reduced by 55 percent. When Partners experts established that a new drug was particularly beneficial for heart problems, orders for that drug increased from 12 percent to 81 percent. When the system began recommending that a cancer drug be given fewer times per day, the percent of orders entered for the lower frequency changed from 6 percent to 75 percent. When the system began to remind physicians that patients requiring bed rest also needed the blood thinner heparin, the frequency of prescriptions for that drug increased from 24 percent to 54 percent.
These improvements not only save lives, they also save money. For starters, the system now recommends cheaper as well as more effective drugs. Even more important, it helps prevent longer hospital stays and repeat tests that result from adverse drug events (ADE). That can save a facility large sums of money, since a 700-bed hospital will normally incur about $1 million per year in preventable ADE costs. Order entry with embedded knowledge is still rare enough that U.S. insurers have not yet seen their costs go down, nor have national malpractice figures changed. However, Partners, which insures itself for malpractice, has some early data suggesting that malpractice reserves can be smaller because of fewer drug-related claims.
Keys to implementing KM
Here is a summary of the non-technical, managerial issues required to keep Partners HealthCare' knowledge management system running smoothly.
Support from the best and brightest. Convincing knowledge workers, no matter what environment or field they're in, to support the system and the new way of working.
An expert and up-to-date knowledge base. Partners uses prestigious committees to identify, refine, and update the knowledge used in each domain.
Prioritized processes and knowledge domains. Since these initiatives are difficult and expensive, they should only be undertaken for truly critical knowledge work processes.
Final decisions by the experts. With high-end knowledge workers like physicians, it would be a mistake to remove them from the decision-making process.
A culture of measurement. In order to justify the time and money spent on an embedded-knowledge system, and to assess how well it's working, an organization needs to have a measurement-oriented culture.
The right information and IT people. An IT organization that knows the business and can work closely with key executives and knowledge-rich professionals is important.