Improving patient safety with Improving patient safety with GP computer systemsGP computer systems

Report on an NPSA-funded Report on an NPSA-funded projectproject

Professor Tony AveryProfessor Tony Avery

University of NottinghamUniversity of Nottingham

BackgroundBackground• There are concerns about patient safety There are concerns about patient safety

in primary care in terms of:in primary care in terms of: Prescribing errorsPrescribing errors Failure to complete intended actions such Failure to complete intended actions such

as patient referrals and medication as patient referrals and medication monitoring monitoring

Failure to respond to abnormal results or Failure to respond to abnormal results or advice from other professionalsadvice from other professionals

Safe and effective communication of Safe and effective communication of information between GPs and patients and information between GPs and patients and professionals in secondary care and professionals in secondary care and community pharmacycommunity pharmacy

Potential role of computer Potential role of computer systemssystems• Computers have considerable potential to Computers have considerable potential to

help GPs to practise safely in terms of help GPs to practise safely in terms of providing:providing:

– Accurate information on patients and drugs at the Accurate information on patients and drugs at the point of decision-making point of decision-making

– Effective decision supportEffective decision support– Intelligent hazard alerts for cautions, Intelligent hazard alerts for cautions,

contraindications, drug interactions and allergiescontraindications, drug interactions and allergies– Help with timely and appropriate monitoring Help with timely and appropriate monitoring – Help with error trapping Help with error trapping – Reporting on patients at riskReporting on patients at risk

Why the need for a project?Why the need for a project?

• While computer systems have While computer systems have considerable potential some problems considerable potential some problems have been highlighted:have been highlighted:– GPs and practice staff may not know how GPs and practice staff may not know how

to make best use of their systems and to make best use of their systems and may not use important safety features may not use important safety features

– GPs may override hazard alertsGPs may override hazard alerts– Computer systems may not contain all Computer systems may not contain all

the safety features that are desirablethe safety features that are desirable

Objectives of the projectObjectives of the project

• To identify the most important safety To identify the most important safety issues regarding GP computer systemsissues regarding GP computer systems

• To assess GP computer systems in To assess GP computer systems in terms of these safety featuresterms of these safety features

• To determine GPs’ knowledge, use and To determine GPs’ knowledge, use and training needs in relation to training needs in relation to computerised safety featurescomputerised safety features

• To work with stakeholders to produce To work with stakeholders to produce specifications for GP computer suppliers specifications for GP computer suppliers and for training practice staffand for training practice staff

Identifying the most Identifying the most important safety issuesimportant safety issues

• Methods used:Methods used:– Stakeholder interviewsStakeholder interviews– Two-round DelphiTwo-round Delphi

Stakeholder interviewsStakeholder interviews

• GPsGPs

• Computer system Computer system supplierssuppliers

• Drug database Drug database supplierssuppliers

• SCHINSCHIN

• RCGPRCGP

• DoHDoH

• NHSIANHSIA

• Design AuthorityDesign Authority

• MDU and MPSMDU and MPS

• Patients’ Patients’ representativerepresentative

• Experts in health Experts in health informaticsinformatics

The Delphi exerciseThe Delphi exercise

• 21 participants21 participants

• Presented with 55 statementsPresented with 55 statements

• 33 statements ranked as important 33 statements ranked as important or very important by over 90% of or very important by over 90% of respondentsrespondents

Key issues from Delphi and Key issues from Delphi and stakeholder interviewsstakeholder interviews• Importance of computerised alertsImportance of computerised alerts• The need to ensure that users record data so that functionality The need to ensure that users record data so that functionality

is available when required is available when required • The need for a drug dictionary for NHS primary care The need for a drug dictionary for NHS primary care • The need for drug ontologies that provide sensible alerts and The need for drug ontologies that provide sensible alerts and

decision support decision support • Avoiding spurious alertsAvoiding spurious alerts• Making it difficult to override critical alerts and to have audit Making it difficult to override critical alerts and to have audit

trailstrails• Effective computer-user interface: ensuring that account is Effective computer-user interface: ensuring that account is

taken of human ergonomicstaken of human ergonomics• Support for safe repeat prescribing Support for safe repeat prescribing • Importance of call and recall: ensuring that intended actions Importance of call and recall: ensuring that intended actions

such as patient referrals and medication monitoring are such as patient referrals and medication monitoring are completedcompleted

• Need to be able to run “safety reports”Need to be able to run “safety reports”

Assessing GP computer Assessing GP computer systemssystems

• From the results of the Delphi we From the results of the Delphi we have developed a series of have developed a series of vignettes/test casesvignettes/test cases

• These have been used on the main These have been used on the main GP computer systems with dummy GP computer systems with dummy patientspatients

• Suppliers were asked to comment Suppliers were asked to comment on the resultson the results

• Results available on Results available on www.bmj.comwww.bmj.com BMJ  2004;328:1171-1172  BMJ  2004;328:1171-1172 

Key points from assessment of Key points from assessment of GP computer systemsGP computer systems

• There are a lot of good features, but we There are a lot of good features, but we have detected some problems:have detected some problems:– Lack of alerts in relation to contraindicationsLack of alerts in relation to contraindications– Spurious alertsSpurious alerts– Failures of drug allergy warningsFailures of drug allergy warnings– Risks of prescribing drugs with similar namesRisks of prescribing drugs with similar names– Lack of warning for methotrexateLack of warning for methotrexate– ““Hidden” alertsHidden” alerts– It is easy to override most alertsIt is easy to override most alerts– Lack of audit trialsLack of audit trials

Determining GPs’ Determining GPs’ knowledge, use and training knowledge, use and training needsneeds

• We have undertaken interviews with GPs: We have undertaken interviews with GPs: – There was a strong sense that they have come There was a strong sense that they have come

to rely on their computers to provide alertsto rely on their computers to provide alerts

• We have developed a questionnaire that We have developed a questionnaire that has been sent to GPs in two sites in has been sent to GPs in two sites in England (387 responses; 64% response England (387 responses; 64% response rate)rate)

Key findings from the Key findings from the GP questionnaire (1)GP questionnaire (1)• The following are regarded as The following are regarded as

important by >90% of GPsimportant by >90% of GPs– computerised alerts computerised alerts

•Allergy alerts (99%)Allergy alerts (99%)• Interaction alerts (99%)Interaction alerts (99%)•Contraindication alerts (99%)Contraindication alerts (99%)

– Need to make it more difficult to Need to make it more difficult to override critical alertsoverride critical alerts

– Systems for recall for patient monitoringSystems for recall for patient monitoring

Key findings from GP Key findings from GP questionnaire (2)questionnaire (2)• GPs are not fully aware of the safety GPs are not fully aware of the safety

features on their computer systems, e.g. a features on their computer systems, e.g. a third of users of a system that doesn’t third of users of a system that doesn’t have contraindication alerts thought that have contraindication alerts thought that the system the system diddid have these alerts! have these alerts!

• Only a minority have had training on the Only a minority have had training on the use of safety features on their computersuse of safety features on their computers

• The preferred method for learning more The preferred method for learning more about the use of safety features is “hands-about the use of safety features is “hands-on” learning with tuition (either one-to-one on” learning with tuition (either one-to-one or in a group setting)or in a group setting)

Stakeholder’s views on how to Stakeholder’s views on how to make improvements to make improvements to systemssystems• System suppliers are willing to make System suppliers are willing to make

changes provided these are sensible and changes provided these are sensible and in keeping with GP opinionin keeping with GP opinion

• Suppliers acknowledge that change is Suppliers acknowledge that change is more likely to take place if this is made more likely to take place if this is made mandatory rather than voluntarymandatory rather than voluntary

• Working through the National Programme Working through the National Programme for IT in the NHS is likely to be the best for IT in the NHS is likely to be the best way of ensuring changeway of ensuring change

Suggestions for improvement Suggestions for improvement in the short-termin the short-term• Act to close the loophole in the recording of allergy Act to close the loophole in the recording of allergy

alertsalerts• Define the most important hazard alerts, ensure these Define the most important hazard alerts, ensure these

are available on all systems and that they cannot easily are available on all systems and that they cannot easily be overriddenbe overridden

• Ensure that system suppliers make full use of Ensure that system suppliers make full use of ontologies available to them, e.g. for contraindication ontologies available to them, e.g. for contraindication alertsalerts

• Develop a computerised “query set” for interrogating Develop a computerised “query set” for interrogating GP computer systems to identify hazardsGP computer systems to identify hazards

• Develop a training package to help practices make best Develop a training package to help practices make best use of the safety features of their clinical computer use of the safety features of their clinical computer systemssystems

Suggestions for improvement Suggestions for improvement in the longer-termin the longer-term• Introduce a drug dictionary for the NHSIntroduce a drug dictionary for the NHS• Evaluate existing ontologies to determine Evaluate existing ontologies to determine

whether these are fit-for-purpose or whether whether these are fit-for-purpose or whether alternatives need to be developedalternatives need to be developed

• Ensure that systems are designed to “make it Ensure that systems are designed to “make it easy to do the right thing”easy to do the right thing”

• Ensure that the design of alert messages take Ensure that the design of alert messages take account of research indicating best practice account of research indicating best practice

• Ensure that health professionals are properly Ensure that health professionals are properly trained to make best use their systemstrained to make best use their systems

• Work to develop safety culture in primary careWork to develop safety culture in primary care

SummarySummary

• GP computer systems already have a number of GP computer systems already have a number of important safety featuresimportant safety features

• There are problems in thatThere are problems in that– GPs have come to rely on hazard alerts when they are GPs have come to rely on hazard alerts when they are

not full-proofnot full-proof– GPs do not know how to make best use of safety GPs do not know how to make best use of safety

features on their systemsfeatures on their systems

• There are a number of solutions that could eitherThere are a number of solutions that could either– Help to improve the safety features of GP computer Help to improve the safety features of GP computer

systemssystems– Help to improve the abilities of healthcare professionals Help to improve the abilities of healthcare professionals

to use these safety featuresto use these safety features