Medical error
According to a US Institute of Medicine report To err is human “at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors. … Deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516)." Medical errors and deviations from best practice are known to have a major impact on the quality and safety of patient care. This is supported by evidence published by partners in this project, which shows that over 10% of admissions to NHS acute hospitals result in adverse events
Delivery of care
Evidence is also accumulating that failing to deliver standard treatment is a problem of epidemic proportions which poses a serious threat to health. McGlynn and colleagues carried out a study of 6712 adults in the United States . Even in the US with its strong commercial drivers patients received only 55% of recommended care overall: only 24% of the diabetics in the study had regular blood tests (needed to avoid complications); people with hypertension received 65% of the recommended care (uncontrolled hypertension increases risk for heart disease, stroke and death); patients with breast cancer and colon cancer received 75% and 50% of recommended care respectively. Studies of this kind do not directly assess harm, but provide important information about conditions in which patients can be harmed.
Accessing knowledge
“Between the health care we have and the care we could have lies not just a gap, but a chasm” according to the Institute of Medicine report Crossing the Quality Chasm The gap between the care patients should receive and what they actually receive has led Sir Muir Gray, Chief Knowledge Officer of the UK National Health Service, to observe that the “application of what is known already will have a greater impact on health and disease than any single drug or technology likely to be introduced in the next decade”.
Safe and sound is setting out to address these problems using a number of advanced Information and Communication Technologies.
Clinical decision support
Research by the Oxford and Edinburgh groups participating in Safe and Sound shows that many kinds of clinical decision can be improved by a factor between 10% and 50% using decision support and other ICT services. Three recent systematic reviews have confirmed the potential value of CDS systems for improving the quality and safety of patient care. Garg et al reviewed 100 studies of simple CDS services, such as alerts and reminders, smart order entry systems, clinical calculators etc and found that they measurably improve outcome in about 70% of studies. If a handful of key design principles are followed benefits are found in 90+ % of studies. More sophisticated applications made possible by partners' technologies have been in use since 1996 (www.openclinical.org/gmm_proforma.html) cover evidence-based decision-making and flexible workflow (Oxford) and care planning (Edinburgh). They have been rigorously evaluated in eight published trials including genetic risk assessment, referral decisions, drug prescribing, image interpretation, multidisciplinary decision making, and treatment planning under risk. The studies uniformly show benefits on a range of measures. In one case a 90% reduction in safety-critical deviations from clinical guidelines for early diagnosis of breast cancer was obtained (reduced from 10% to 1%) and in another deviations from the protocol for treating leukaemia in children (23%) were eradicated.
Knowledge access and sharing
The sheer quantity of medical information, even within a single specialty, is often beyond the power of one person to apply effectively (Bates and Gawande). For instance, more than 600 drugs require adjustment of doses for multiple levels of renal dysfunction; an easy task for a computer but inevitably done poorly by a person1. The disparity between human capabilities and the results that it should, given our knowledge, be possible to achieve has led to the situation in which patients receive varying levels of care, with the likelihood of recovery often dependent on which medical centre the patient visits. Adverse events which seriously impact the health and even the lives of patients are all too common.
Flexible service management
Coordinating the care of patients can be an immensely complicated process. To take just one example from our case study the diagnosis and treatment of cancer patients can involve hundreds of people in a number of settings over a period of months or years. Patients are often very grateful for the care they receive from individual clinicians, but experience the overall process as fragmented and at times chaotic. Clinicians too expend huge amounts of time assembling information and attempting to coordinate care, time which would be better devoted to direct patient care. The published evidence on benefits of IT to improve clinical workflow is much smaller than that for clinical decision support but it is generally believed that errors in recording clinical data, placing clinical orders and failures of communication probably all play a role in findings such as those of the McGlynn study, predispose to adverse clinical events, and give rise to substantial clinical morbidity and mortality. A 2004 Frost and Sullivan report on the European healthcare industry asserts that the benefits of better compliance with clinical pathways and workflows and physician order entry systems for better healthcare quality together with cost-control are “proven”.
