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If Electronic Hospital Systems are the answer, what are the problems

?Medical care is mind-numbingly complex. . Medicine today involves a vast, fragmented, often isolated array of human, technical, and institutional resources. It operates in a labyrinthine legal and regulatory environment that makes Dante's Inferno look like a stroll in the park. And it conducts its business with systems so archaic and incentives so perverse that the nation's education system looks almost rational by comparison." - David Lawrence, MD.

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If Electronic Hospital Systems are the answer, what are the problems

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    1. If Electronic Hospital Systems are the answer, what are the problems? Dato Dr Jai Mohan, FRCP, FAMM Vice-President, Malaysian Health Informatics Association Director, Healthcare Informatics, Solutions Protocol jmohan@streamyx.com

    2. Complexity of Medical Care

    3. 1st Curve Craft-based Culture The craft person defines quality. Quality is what emanates from the applied skills, dedication and vigilance of the craft person. Quality thus flows from building processes around the craft person(s). Quality assurance is best achieved by craftpersons checking on craft persons (peer review) If something goes wrong, someone is at fault. Systems theory and organizational complexity are unknown/irrelevant, and health administration is isolated from and tangential to the primary work.

    4. The Real Problem . .? Complex health care processes relying on a craft cultures focus on vigilance and people checking people, and thus unsupported by a carefully designed error-proofing/mitigating infrastructure have a performance capability ranging between 2 - 4 sigma.

    5. where we are/need to be

    6. Inevitable consequences of 2-4 sigma

    8. Far from being the culprits of medical errors, caregivers are in fact the patients last line of defense, the last safety net that most often protects patients from poorly conceived and/or dangerous care processes. But, given the inherent dangers our complex health care enterprise represents, care processes relying on human competence and vigilance for safety will inevitably fail at rates far exceeding acceptability.

    9. Put very, very simply: the people work well by and large, but the system often does not. Every hour of our care reminded me, and alerted Ann, about the enormous, costly, and painful gaps between what we got in our days of need, and what we needed. The experience did not actually surprise me, but it did shock me. Put in other terms, as a friend has said about me, before this, I was concerned; now I am radicalized. - from Excape Fire, Donald M. Berwick, MD, MPP, Plenary Address, 11th Annual National Forum on Quality Improvement in Health Care,,December 9, 1999

    10. 2nd Curve Collaborative Culture of Safety/Excellence Quality is multi-dimensional (the Balanced Scorecard). Quality emanates from the careful design of clinical microsystems and the coordinated skills of caregivers, patients, and community stakeholders. Microsystems are designed around the needs of those served, in a manner that maximizes caregiver effectiveness and satisfaction as well. Quality is constantly measured in real time, within a consciousness of vigilance regarding errors, error-provoking situations, and opportunities to improve systems. Errors, glitches and near misses are viewed as learning opportunities, freely reported in a just culture (AHRQ). Caregivers practice MINDFULLY, within a consciousness of interdependency among all caregivers and managers, and the importance of a solid systems infrastructure.

    13. John Maynard Keynes The hardest thing is not to get people to accept the new ideas, it is to get them to forget the old ones.

    14. What might I do . . . ? Make yourself what you want the world to become. - Mohandas Gandhi The first step is the transformation of the individual. - W. Edwards Deming

    25. Medicine in the Information Age: Just-in-Time Information at the Point-of Care

    43. From several presentations at ASHP: Ordering: 56% of errors initially -> 45% of these are caught = 41% Excluding Ordering: Dispensing: 4% of errors initially -> 37% of these are caught = 4% 6% Transcribing: 6% of errors initially -> 23% of these are caught = 7% 11% Administration: 34% of errors initially -> 0% of these are caught = 48% 83% -------- -------- -------- 100% 100% 100%From several presentations at ASHP: Ordering: 56% of errors initially -> 45% of these are caught = 41% Excluding Ordering: Dispensing: 4% of errors initially -> 37% of these are caught = 4% 6% Transcribing: 6% of errors initially -> 23% of these are caught = 7% 11% Administration: 34% of errors initially -> 0% of these are caught = 48% 83% -------- -------- -------- 100% 100% 100%

    73. Chronic Disease Management: Are patients getting the care they deserve? Dato Dr Jai Mohan, FRCP, FAMM Vice-President, Malaysian Health Informatics Association Director, Healthcare Informatics, Solutions Protocol jmohan@streamyx.com

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