Knowledge Management Helps Cut Errors by Half

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July 08, 2002 (Computerworld) -- At Partners HealthCare System Inc., which includes some of Boston's most prestigious teaching hospitals, a knowledge management system for physicians has reduced serious medication errors by 55%. John Glaser, CIO at Partners, has been at the helm of this effort for more than a decade, bringing just-in-time knowledge to bear on life-and-death decisions. In this month's Harvard Business Review, he reports on progress and lessons learned with co-author Thomas H. Davenport, director of Accenture Ltd.'s Institute for Strategic Change in Cambridge, Mass. Computerworld's Kathleen Melymuka, who first reported on the project a decade ago, spoke with Glaser recently to get an update about how the system is working.

Going way back, what was the impetus behind the knowledge management initiative? Two things were at play: We know physicians are human beings and there's too much for them to know. If we could build in help for that decision at the time of decision—where decisions are played out as action—that would have a lot of power.

That thought ran in parallel with a Harvard study that was looking at the rate of medical errors at Brigham [and Women's] and Mass. General [hospitals]. The error rate was just too high, and very simple things were causing a good chunk of the problem—things like not knowing a patient was allergic to a drug or forgetting that two drugs interacted badly.

This is the latest in a series of monthly discussions with authors of articles in the Harvard Business Review on topics of interest to IT managers.

It seems that the key to this system is that it pushes information to doctors, rather than having them search for it. The general notion is "just in time." The computer knows that you're trying to enter an order. It knows a lot about the patient—test results, other drugs, diagnosis; and [it knows] something about medicine—what goes together. It applies all this and makes a judgment, and about 400 times a day, a physician changes his mind on an order based on the computer. That's only 3% [of all orders], but it's catching something in the workflow when the physician may not be aware he needs the knowledge.

How readily do doctors accept this unsolicited advice? We were smart in starting with advice on no-brainers: Telling that a patient is allergic to a drug or that two drugs together is a bad combination.

Would they rather we didn't tell them? Of course not. But we didn't go into a class of guidance that is debatable.

How big a factor is the extra time it takes to use the system? The biggest problem is that we're adding 30 minutes to the average 12-hour day. They're working hard already, and they're thinking, "I'm not sure I'm the guy who's making the mistakes. It's probably that other guy." But a while ago a physician pulled me aside and said, "I just want to tell you our system has saved my ass a couple times."

What are the special difficulties in designing a knowledge management system for high-end knowledge workers such as doctors? Physicians don't have a lot of time. They have to sign on, identify the patient, pick the drug and the dose. Getting that to take as little time as possible is nontrivial, particularly with quick orders like changing a dose. So there was a design challenge in the workflow. Also, this was a system that would challenge their decisions, so it had to be a nonthreatening intervention that can be overridden. Then there was the nature of the infrastructure. Scheduled downtime is not a good idea, because physicians never stop writing orders.

I bet there were nontechnical challenges as well. There were challenges in the medical/legal sense: Are we making our problems worse? If the system doesn't challenge you, is it working? If you overrode and you shouldn't have, would there be trouble? It was complex potential liability territory.

Have the financial benefits justified the costs? People are still debating that. There's not a lot of good study. We have data that says each adverse drug event can cost $6,000 in additional days you spend in the hospital, additional tests—the true costs to society. But there are goofy economics in health care because we might get paid for those additional days, so it gets complicated. Only about 3% of hospitals have systems like this. That's because it's hard, but also because the ROI is fuzzy and messy. The justification has got to be more on the social-good side than the bottom-line side.

How much of what you've learned is applicable to industries outside of health care? The world is full of large numbers of knowledge workers whose knowledge is played out in transactions—they order something, document something—and the domains of knowledge they work with are more than they can cram into their heads. And even if they can, they still have lapses, and knowledge is quite volatile so we need ways to help them make better decisions. It might be harder for a lawyer, but it might work for a biochemist looking at a new compound. The computer has knowledge about chemistry and interactions, and it can apply rules behind a task being done. To the degree that a decision is made and expressed as a transaction, one has the ability to leverage this.

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Knowledge Management Helps Cut Errors by Half

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