Saving Patient Ryan Can Advanced Electronic Medical Records Make Patient Care Safer? Zia Hydari SMU Living Analytics Research Centre Seminar July 2015 (Joint work with Rahul Telang and Bill Marella) Working Paper: http://ssrn.com/abstract=2503702 For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 1
Acronyms Acronyms Meaning EMR CPOE PD Electronic Medical Records Computerized Provider Order Entry Physician Documentation PSA The Pennsylvania Patient Safety Authority For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 2
The Problem Patient Safety Patient safety can be defined as freedom, as far as possible, from harm, or risk of harm, caused by medical management (as opposed to harm caused by the natural course of the patient s original illness or condition). 1 Extent of Medical Errors in Hospitals Third leading cause of death in the US 2 Hundreds of thousands harmed or at risk of harm Tens of billions of dollars in cost to society 3 (1) Great Britain House of Commons Committee, Patient Safety, Sixth Report, (2) Senator Bernard Sanders, Subcommittee on Primary Health and Aging More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety (July 2014), (3) Bos, J. V. D. et al. The 17.1 Billion USD Problem: The Annual Cost Of Measurable Medical Errors. Health Aff 30, 596 603 (2011). For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 3
Health Information Technology (IT) Federal incentive payments $27 billion for health IT adoption 1 Hospitals investing significantly in health IT - IT spending 20% of hospital capital spending - Healthcare IT market $22 billion in 2012 EMR impact on patient safety major societal concern - High interest from public policy makers, payers, and hospital managers 1. Federal HITECH Act funding with the purpose of reducing costs and improving outcomes Sources: S&P Capital IQ Industry Surveys Healthcare : Facilities, p. 21 (December 2013) ; Essentials of the U.S. Hospital IT Market, HIMSS Analytics; Hospital IT spending jumps high, Healthcare IT News (August 2013), HITECH abbreviates Health Information Technology Economic and Clinical Health, For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 4
Related Literature on Health IT Effects Reference Outcome Study Period Miller and Tucker (2011) Neonatal mortality 1995-2006 Agha (2014) McCullough, Parente, and Town (WP 2013) Parente and McCullough (2009) Freedman, Lin, and Prince (WP 2014) Mortality, complications, readmission, ADE for Medicare patients Mortality in fee-for-service Medicare patients 3 Patient Safety Indicators (PSI) for Medicare patients 4 postoperative PSIs from Nationwide Inpatient Sample 1998-2005 2002-2007 1999-2002 2003-2010 For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 5
Health Policy Stakeholders Assessment of Evidence current literature is inconclusive regarding the overall impact of health IT on patient safety (IOM, 2012) most of the outcomes are measured using billing data... and they are truly, near worthless... (Peter Pronovost*, MD, 2014) IOM. 2012. Health IT and Patient Safety: Building Safer Systems for Better Care. Accessed July 30, 2013. http://books.nap.edu/openbook.php?record_id=13269. IOM. 2011. Health IT and Patient Safety Appendix B: Literature Tables (online). http://www.nap.edu/html/13269/app_b_tables.pdf. US Senate Subcommittee on Primary Health and Aging - More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety (July 2014) * Peter Pronovost pioneered checklist protocol for reducing the deadly infections associated with central line catheters (bio). For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 6
Why is existing evidence inconclusive about effect of EMRs on patient safety? Partly lack of reliable patient safety data and partly unconvincing analysis For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 7
Patient Safety Data For this Study Comprehensive - Broad categories of patient safety events - All patient ages, diseases, and conditions - Inpatient and outpatient events State law mandates accurate reporting - Hospitals promised data confidentiality - Hospitals penalized for failure to report - Whistleblower protection PSA collects all data Record identifies category, date, hospital, and includes text report PSA possibly the best available source for patient safety data For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 8
Advanced Electronic Medical Records Computerized Provider Order Entry (CPOE) - Process and transmit medication, laboratory, and radiology orders digitally - Integrate patient data, decision support, best practices 1 into clinical workflow Physician Documentation (PD) - Record diagnoses, treatment plans, and clinically relevant events digitally for patient over time - Consolidate progress notes across departments - Enable coordination across care providers such as physicians and pharmacists Advanced EMR = CPOE or PD 2 1 ZynxHealth integration with Epic; PatientOrderSets.com integration with Cerner 2 Defined by Dranove et al. Used by McCullogh et al; Freedman et al; Li etc. [Dranove, David, Christopher Forman, Avi Goldfarb, and Shane Greenstein. The Trillion Dollar Conundrum: Complementarities and Health Information Technology. American Economic Journal: Economic Policy, 2014. https://www.aeaweb.org/forthcoming/output/accepted_pol.php]. For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 9
Mechanisms of EMR Impact on Patient Safety Why errors in modern medicine? 1 Work complexity Knowledge intensiveness Variety and volatility of circumstance 14,000 diagnoses 6,000 drugs 4,000 medical, surgical procedures Source: Atul Gawande, MD Patient safety improves because EMRs: 2 Improve communications Make knowledge accessible Provide decision support Require key pieces of information for correct treatment Assist with calculations Perform real-time checks Assist with monitoring 1. Spear, Steven J., and Mark Schmidhofer. "Ambiguity and workarounds as contributors to medical error." Annals of Internal Medicine 142, no. 8 (2005): 627-630. 2. Bates, David W., and Atul A. Gawande. 2003. Improving Safety with Information Technology. New England Journal of Medicine 348 (25): 2526 34. For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 10
Summary of Main Results Advanced EMR adoption leads to: 27% decline in all (aggregated) events 30% decline in medication events 25% decline in complication of procedure, test, or treatment Medication events include incorrect medication lists, unauthorized drugs, omitted/extra/wrong dosage, prescription delays, monitoring errors, or inadequate pain management (but not adverse drug reactions). Complications of procedure, test, or treatment include complication following surgery or invasive procedure, anesthesia event, emergency department, maternal complication, neonatal complication, nosocomial infection, cardiopulmonary arrest outside ICU, IV site complication, extravasation of drug or radiologic contrast, catheter or tube problem, onset of hypoglycemia, and complication spinal therapy For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 11
Data Sources For This Study Patient Safety Events Source PSA Description All patient safety events for 2005-2012 in Pennsylvania Hospitals EMR Adoption HIMSS Adoption of Basic EMR (CDR, CDSS) and Advanced EMR (CPOE, Physician Documentation) and non-clinical IT for 2005-2012 Hospital Controls PHC4, AHA, CMS In-patient days, teaching status, residency status, JCAHO, medical school, transfer-adjusted case mix index County Controls AHRF Population; percent white; percent over 65; unemployment, household income For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 12
EMR Adoption in Pennsylvania Hospitals Advanced EMR CPOE PD [Dranove 2014] 40 50 60 70 80 2004 2006 2008 2010 2012 Year Includes only hospitals with observations for all years. CDR: Clinical Data Repository; CDSS: Clinical Decision Support System; CPOE: Computerized Physician Order Entry; Dranove, David, Christopher Forman, Avi Goldfarb, and Shane Greenstein. The Trillion Dollar Conundrum: Complementarities and Health Information Technology. American Economic Journal: Economic Policy, 2014. https://www.aeaweb.org/forthcoming/output/accepted_pol.php. For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 13
Methods Unit of analysis Outcome Research Design Time-variant Controls Time-invariant Controls Hospital-year Log of patient safety events Differences-in-differences Inpatient days (hospital size), case mix index 1 Interacted with linear time trend County: population, household income, age over 65 years Hospital: teaching, residency, medical school, JCAHO Identification Conditional on controls, EMR adoption uncorrelated with error 1. Case Mix Index used in robustness check For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 14
Model Specification Log (# PATIENT SAFETY EVENTS) it = β 0 + β 1 ADVANCED EMR it +β 2 Log HOSPITAL SIZE it + β 3 BASIC EMR it +Β 4 HOSPITAL CONTROLS i YEAR + Β 5 COUNTY CONTROLS i YEAR + HOSPITAL FIXED EFFECTS i + YEAR FIXED EFFECTS t + ERROR it For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 15
EMR Adoption and Patient Safety Events (1) b/p (2) b/p (3) b/p (4) b/p Advanced EMR -0.24** -0.28** -0.28** -0.27** 0.048 0.021 0.019 0.017 Hospital Size Basic EMR Control No No No Hospital Controls 1 No County Controls 1 No No Year and Hospital FE Variance-Covariance Est. cluster cluster cluster cluster Observations 952 952 952 952 Hospital and country controls are included in the model as interaction terms with a linear time trend For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 16
Medication Errors Incorrect medication lists Unauthorized drugs Dosage Omitted Extra Wrong Prescription delays Inadequate pain management For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 17
EMR Adoption and Medication Errors Log of Medication Errors (b/p) Advanced EMR -0.30** 0.01 Hospital Size Basic EMR Control Hospital-level Controls County-level Controls Year and Hospital FE Variance-Covariance Estimator cluster Observations 932 For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 18
Alternate Explanations Differential trends at adopting hospitals: - Patient safety initiatives - Training programs EMR causing changes: - Reporting - Case mix Patient safety events causing adoption at peak Measurement errors in outcome and treatment For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 19
Ruling Out Alternate Explanations Alternate Explanation Selection: Patient safety initiatives at adopting hospitals Unobserved hospital ability correlated with IT adoption and patient safety Falsification or Robustness Check No effect on skin integrity events (falsification test with placebo outcome) No effect of lead value of EMR on patient safety events No effect of non-clinical IT Effect of Advanced EMR persists with non-clinical IT as covariates Reverse causality Lagged events (and changes) do not predict Advanced EMR adoption Sample issues (outliers etc.) Similar effects with balanced panel and balanced panel with basic EMR throughout study Skin integrity events include pressure ulcers, burns, rashes / hives, abrasions, lacerations, blisters, and skin tears. These events are problems with patient positioning, movement, or manipulation; or physical environment; or use of devices near or on patients so no expected effect from IT Non-clinical IT includes revenue cycle management, general financials, financial decision support, human resources, and supply chain management. For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 20
Skin Integrity Events (Placebo Outcome) Pressure ulcers Burns Rashes / hives Abrasions Lacerations Blisters Skin tears Problems with patient positioning, movement, or manipulation; or physical environment; or use of devices near or on patients so no expected effect from IT For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 21
No Effect of Advanced EMR on Skin Integrity Log of Skin Integrity Events (b/p) Advanced EMR 0.01 0.87 Hospital Size Basic EMR Control County Level Controls Hospital Level Controls Year and Hospital FE Variance-Covariance Estimator cluster Observations 902 For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 22
Non-Clinical IT Adoption and Patient Safety Non-clinical IT systems - Revenue Cycle Management - General Financials - Financial Decision Support - Human Resources - Supply Chain Management No direct impact on patient safety Control for unobserved hospital ability 1 1: Unobserved hospital ability that is correlated with non-clinical IT adoption, clinical IT adoption, and patient safety events. For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 23
Non-Clinical IT and Patient Safety Log Events b/p Log Events b/p Advanced EMR -0.26** 0.03 General Financials -0.08-0.08 0.33 0.37 Financial Decision Support -0.02-0.03 0.57 0.53 Human Resources 0.02 0.01 0.61 0.86 Supply Chain Management -0.10-0.09 0.30 0.37 Revenue Cycle Management -0.01-0.00 0.67 0.89 Hospital Size Year and Hospital FE Hospital Controls County Controls Variance-Covariance Estimator cluster cluster Observations 951 951 For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 24
Patient Safety Events and Lead EMR Adoption Log of PS Events (b/p) Lead(1) Advanced EMR 0.055 0.411 Hospital Size Hospital and Year Fixed Effects Time-Interacted Hospital Controls Time-Interacted County Controls Basic EMR Control Variance-Covariance Estimator cluster Observations 499 For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 25
EMR Adoption and Patient Safety Events Case Mix Control Log of PS Events (b/p) Advanced EMR -0.18** 0.04 Transfer Adjusted Case Mix Index PSA ereporting Hospital Size Hospital and Year FE Basic EMR, Hospital, County Controls Variance-Covariance Estimator cluster Observations 852 For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 26
EMR Adoption and Skin Integrity Events Case Mix Control Log of Skin Events (b/p) Advanced EMR 0.01 0.88 Transfer Adjusted Case Mix Index PSA ereporting Hospital Size Hospital and Year FE Basic EMR, Hospital, County Controls Variance-Covariance Estimator cluster Observations 852 For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 27
Reverse Causality Alternate Explanation: Hospitals adopting EMRs when patient safety events are at peak Events regress to mean rather than decline due to EMRs Check for: Do patient safety events predict EMR adoption? For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 28
Lagged Safety Events and EMR Adoption BLPM1 b/p BLPM3 b/p Lag(2) All Events 0.0034 0.0056 BLPM5 b/p 0.9968 0.9927 Lag(2) All Events -0.0009 0.9994 Lag(2) Patient Days -0.0003-0.0013 0.9995 0.9501 Variance-Covariance Estimator bootstrap bootstrap bootstrap Replications 1000 1000 1000 Seed 11 11 11 Observations 144 89 89 Note: Dependent variable is lagged adoption of Advanced EMR For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 29
Limitations Instruments Patient safety initiatives not directly observed (measured) Measurement Issues - Coarse EMR adoption measure - Reports correlated with actual events but not perfectly - HIMSS survey inaccuracies SUTVA 1 violations - Hospitals differ in meaningful EMR usage - Hospitals use different EMR products - Spillover effects over units (especially private practice physicians credentialed at multiple hospitals) 1. SUTVA: Stable Unit Treatment Value Assumption; see Imbens, Guido and Donald Rubin (2014) For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 30
Future Work Economic returns of advanced EMRs from patient safety Finer measurement of EMR usage Analysis of patient safety event text reports Distributional changes in reported events due to EMR adoption Events caused by health IT and especially EMRs For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 31
Conclusion Causal effect of advanced EMRs on patient safety New comprehensive data set and careful analysis Substantive and significant findings 27 percent decline in overall events 30 percent decline in medications events 25 percent decline in complications events Alternate explanations ruled out with robustness checks Results relevant to policy makers, hospital managers, and patients For Carnegie distribution Mellon within University SMU only Saving Patient Ryan Can 70-451 Management Advanced Information Electronic Systems: Medical Spring Records 2012 Make Patient Care Safer? 32