Utilising live patient dashboards to improve VTE risk assessment and prevention Dr Anthony Barberi Western Health, Victoria Medical Informatics Registrar MBBS, BDSc
“..we should think twice before ordering our patients to bed and realise that beneath the comfort of the blanket there lurks a host of formidable dangers.” Source: Dangers of going to bed, R.A.J. Asher, British Medical Journal, 13 December 1947 Footer Text 2
National Clinical Care Standard ___ Why VTE Venous Thromboembolism Prevention Clinical Care Standard, Australian Commission on Quality & Prophylaxis? Safety in Healthcare Already Measured in our Institution ___ “A large proportion of hospitalised patients Internal Policy and Procedure around management, are at risk for VTE, but there is a low rate of risk stratification and prevention in place. appropriate prophylaxis. ” ENDORSE Study, Cohen et al, Lancet 2008 Clinical Importance Hospital Wide ___ VTE prevention is seen by clinicians as an important part of patient care, in most inpatient care settings. Footer Text 3
How should Risk Assessment Completed ___ VTE prevention High or Low Risk Populations be performed in hospitals? Pharmacological & Patient Care Interventions Determined based on Risk Assessment Reassessment Throughout Change in clinical status Ie: Major procedures, immobility, diagnoses Footer Text 4
Our Goals CLINICAL (Primary) • Provide Real-time data direct to clinicians and management about inpatient VTE Risk • Provide data to clinicians to identify anomalies in preventative measures • Identify at risk patients quickly QUALITY & SAFETY • Demonstrate our efforts to align with Clinical Care Standards • Recognise at risk areas to provide support DATA INTEGRITY • Improve the data quality recorded within the EMR WORKFLOW IMPROVEMENT • Provide a tool to identify pitfalls in the electronic workflow Footer Text 5
Our Boundaries/Limitations 1. Not a replacement for the patient’s record Limit information to users 2. Not supported by clinical grade servers and IT support cannot replace core clinical/administrative workflows (particularly prescribing) Footer Text 6
Method Power BI Dashboard Cerner EMR iPM Patient Patient Care Patient Admission Surgical Medications Location & Tasks Details Time Procedures Medical team Footer Text 7
It seemed like a good idea at the time… Footer Text 8
But when I said we were “already measuring”… Footer Text 9
Clinical Care Standard Steps in Prevention Further Assessment Assessment within after any Major Reassessment Assessment on Admission 24 hours Procedures/Change every 7 days Discharge in Clinical Status EMR Alert begins firing Footer Text 10
Alert Fatigue… and an exercise in human behavioural science… Up to 40,000 alerts a month = Up to an alert approximately every minute. Footer Text 11
VTE Live Dashboard Footer Text 12
Missing Data in the Real World Footer Text 13
Missing Data: No Risk assessment, but being treated Footer Text 14
Missing Data Frank’s father has 5 sons. If the names of his 4 sons are Fefe, Fifi, Fofo, Fufu, respectively, then what would be the name of his 5th son? Footer Text 15
Missing Data Frank’s father has 5 sons. If the names of his 4 sons are Fefe, Fifi, Fofo, Fufu, respectively, then what would be the name of his 5th son? Footer Text 16
Contradictory Data: Workflow vs Knowledge Gap? Footer Text 17
Anomalous Results Tracker Footer Text 18
Historical Reporting: in the hands of clinical staff Footer Text 19
Future enhancement Power BI Dashboard Riskman & Cerner EMR iPM Adverse Events Data Patient Hospital Patient Care Surgical Medications Patient Details Location & Admission Time Associated VTE Tasks Procedures Medical team complications Footer Text 20
Lessons Learnt & Challenges • Organisational Readiness for what you’re going to uncover • Ethics of non-action as a clinical informatics team – retrospective audits vs live data where you can change outcomes • Dashboard external to clinical applications has many pros and some cons • Focus on accreditation standards – low hanging fruit, organisation impetus, lets you test your system • Focus on well defined, well documented data points • Live data with clinician input helps recognise limitations in electronic workflow easier than retrospective audits Footer Text 21
The Real Challenge: Footer Text 22
“We need to recognise that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12. Instead, they transform the work, the people who do it, and their relationships with one another and with patients” - Robert Wachter, The digital doctor Footer Text 23
The conceptual leap clinicians need to make… - Retrospective - Data poor - Too late to treat - More suited to auditing & research purposes than at the coalface care Footer Text 24
The conceptual leap clinicians need to make… - Live data - Data rich - Allows active intervention at patient level - Live monitoring, rather than auditing - Overwhelming unless well curated Footer Text 25
Thank you to the Western Health staff who actually do all the work: Mathew Long Sean Downer Rick Horton Jen Tiet EMR Operations Team MaP Team Footer Text 26
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