Health, Medicine, Nursing Case Study: Importance of knowledge management system in dialysis units

In the assigned article “Just-in-Time Delivery Comes to Knowledge Management” the embedded knowledge in the Health Information System aids physicians in making better informed decisions thereby decreasing medical errors. Select any type of medical facility and discuss how such a system might improve their healthcare delivery. (Please keep your response to one page - no more than two pages. Ensure proper citations are utilized)
Just-in-Time Delivery
Comes to Knowledge Management
by Thomas H. Davenport and John Glaser

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Best Practice
Just-in-Time Delivery Comes
to Knowledge Management Thomas H. Davenport and John Glaser

Just-in-Time Delivery
Comes to Knowledge Management
Dr. Bob Goldszer is the associ- ate chief medical officer and head of the Special Services
Department at Brigham and Women’s in Boston, one of the nation’s leading hospitals. A professor at the Harvard Medical School, Goldszer has both an MD and an MBA. He’s a high-end knowl- edge worker at the top of the medical profession.
Yet Dr. Goldszer has a big problem – one common to all physicians. There is so much knowledge available about his work that he cannot possibly absorb it all. He needs to know something about almost 10,000 different diseases and syndromes, 3,000 medications, 1,100 lab- oratory tests, and many of the 400,000 articles added each year to the biomed- ical literature. Even if he were to consult only those articles written by his col- leagues at Partners HealthCare (the Boston-based umbrella organization that includes Brigham and Women’s, Massachusetts General, and several other hospitals and physicians’ groups), he would need to choose among 202 on
hypertension, 139 on asthma, and 313 on diabetes. As a primary care physi- cian, he must know something like a million facts, and those facts are con- stantly changing. Clearly, it is difficult for Goldszer to stay on top of even a fraction of all the new knowledge being generated in his field and still do his job.
This is not a trivial problem. It is, quite literally, a matter of life and death. Over the past decade, researchers have done a series of studies on medical errors. The results are sobering. The Institute of Medicine’s 1999 report To Err Is Human suggests that more than a million in- juries and as many as 98,000 deaths each year are attributable to medical er- rors. Partners’ own research in 1995 sug- gested that more than 5% of patients had adverse reactions to drugs while under medical care; 43% of those inpa- tient reactions were serious, life threat- ening, or fatal. Of the reactions that were preventable, more than half were caused by inappropriate drug prescrip- tions. About a third of the marginally abnormal pap smears and mammograms
Best Practice
Knowledge-sharing programs often fail because they make it harder, not easier, for people to do their jobs. But the novel approach taken by Partners HealthCare offers hope.
Copyright © 2002 by Harvard Business School Publishing Corporation. All rights reserved.
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by Thomas H. Davenport and John Glaser
BEST PRACTICE • Just-in-Time Knowledge Management
received no documented follow-up. A study of the six most common labora- tory tests ordered by physicians in Brig- ham and Women’s surgical intensive care unit found that almost half of the tests ordered were clinically unneces- sary. Another study at the Brigham found that more than half of the pre- scriptions for a particular heart medi- cine were inappropriate.
Some of these mistakes result from carelessness, but far more of them, we believe, occur because the clinicians must track such massive amounts of complex information. The problem of staying on top of all the knowledge available in a given profession is not restricted to medicine, of course. Knowledge work- ers in many other fields have problems similar to Dr. Goldszer’s, though gener- ally theirs are less life threatening. No matter what the industry, knowledge workers often can’t keep up with the knowledge being generated. And al- though failure to keep up with current information may not result in deaths, it can lead to less successful projects and products, wasted resources, and broken businesses.
Knowledge management, which was all the rage in the mid- to late 1990s, is still a good idea, but it needs a new ap- proach. In the early years of knowledge management, companies established employee networks and communities of practice, built knowledge reposito- ries, and tried to encourage information sharing. Knowledge workers were ex- pected to participate in these activities in addition to doing their regular jobs. That meant staying a little later each night to share what they’d learned in the course of doing their jobs and com- ing in a little earlier each morning to learn from others. As a result, the pro- grams, many of which continue today, have been only marginally successful.
Even the successful ones require motiva- tional schemes and some arm-twisting from senior executives.
But there is a better approach to in- formation sharing and retrieval. The key to success, we’ve found, is to bake spe- cialized knowledge into the jobs of highly skilled workers – to make the knowledge so readily accessible that it can’t be avoided. This is the main ap- proach Partners HealthCare has taken to address Dr. Goldszer’s problem. Part- ners has made his job easier by helping him avoid mistakes, learn from other employees’ experiences, and access im- portant information when he needs to make decisions. While there are several ways to bake knowledge into knowl- edge work, the most promising ap- proach is to embed it into the technol- ogy that knowledge workers use to do their jobs. That approach ensures that knowledge management is no longer a separate activity requiring additional time and motivation.
We believe that this method could revolutionize knowledge management in the same way that just-in-time sys- tems revolutionized inventory man- agement – and by following much the same philosophy. In this article, we’ll discuss how just-in-time knowledge has been embedded into Dr. Goldszer’s work and other physicians’ work at a few Partners hospitals. We’ll also con- sider the circumstances that make it possible – or impossible – to bake knowl- edge into the work processes of other high-end professionals.
Partners’ Ambitious Project
Embedding knowledge into everyday work processes is time-consuming and expensive. It’s not an undertaking that anyone in his right mind would tackle without a very good reason. A decade ago, Partners had that reason: Researchers at the Harvard School of Public Health and Harvard Medical School found that there were surprisingly high numbers of medical errors and adverse drug re- actions at Partners hospitals. That these institutions could be unconsciously act- ing in direct opposition to their healing mission was deeply troubling.
Under the direction of H. Richard Nesson, CEO of Brigham and Women’s at the time, Partners undertook an am- bitious and risky project to link massive amounts of constantly updated clinical knowledge to the IT systems that sup- ported doctors’ work processes. The proj- ect was ambitious because it had the po- tential to substantially improve the
The key to success is
to bake specialized knowledge into the jobs of highly skilled workers – to make the knowledge so readily accessible that it can’t be avoided.
quality of physicians’ decision making – and hence improve the quality of pa- tient care. But it was also risky because knowledge-based systems had a very spotty record of success in their first in- carnation two decades ago and because Partners didn’t really know if it would be able to codify the millions of facts and data points that doctors use to make complex decisions about treatment.
So the project was defined relatively narrowly at first. Partners professionals targeted an essential work process – physician order entry – and a problem that was well documented – errors in drug prescriptions and lab-test order- ing. Drug interactions are relatively straightforward and easy to program; this fact, too, improved the project’s chances for success.
The decision to focus on the order- entry system was important because the system is central to physicians deliver- ing good medical care. When doctors order tests, medications, or other forms of treatment, they’re translating their judgments into actions. This is the mo- ment when outside knowledge is most valuable. Without the system, doctors would have no easy way to access oth- ers’ knowledge in real time. Automated
Thomas H. Davenport is the director of Accenture’s Institute for Strategic Change in Cambridge, Massachusetts, and a man- agement professor at Babson College in Wellesley, Massachusetts. John Glaser is the vice president and CIO of Partners HealthCare System in Boston.
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order entry addresses this need in sev- eral ways: It increases efficiency and safeguards against errors due to poorly written orders. Even more important, it allows physicians easy access to massive amounts of up-to-date medical knowl- edge while they go about their daily work. Indeed, the order-entry system forces physicians to engage with queries or recommendations (although, as we shall see, they can always override the system’s recommendations).
Order entry is a key work process in this system, but it’s not the only one. Partners’ approach is built on a set of integrated information systems – in- cluding on-line referral and medical- records systems – that physicians can use to manage patient care. These all draw from a single database of clinical infor- mation and use a common logic engine that runs physicians’ orders through a series of checks and decision rules.
Here’s how it works. Let’s say Dr. Goldszer has a patient, Mrs. Johnson, and she has a serious infection. He de- cides to treat the infection with ampi- cillin. As he logs on to the computer to order the drug, the system automati- cally checks her medical records for al- lergic reactions to any medications. She’s never taken that particular med- ication, but she once had an allergic re- action to penicillin, a drug chemically similar to ampicillin. The computer brings that reaction to Goldszer’s atten- tion and asks if he wants to continue with the order. He asks the system what the allergic reaction was. It could have been something relatively minor, like a rash, or major, like going into shock. Mrs. Johnson’s reaction was a rash. Gold- szer decides to override the computer’s recommendation and prescribe the orig- inal medication, judging that the posi- tive benefit from the prescription out- weighs the negative effects of a relatively minor and treatable rash. The system lets him do that, but it requires him to give a reason for overriding its recom- mendation.
The fact that the order-entry system is linked not just with the clinical data- base but also with the patient’s records increases its usefulness by an order of
magnitude. The system may inform Goldszer that a drug being prescribed is not economical or effective, but it can also tell him that the patient is taking another drug that interacts badly with the new medication or one that might exacerbate a condition other than the one being treated. When it comes to or- dering tests for a patient, the system may note that a particular test is gener- ally not useful in addressing the symp- toms identified or that it has been per- formed on the patient enough times that a retest would not be useful.
That’s a relatively simple explana- tion of what the integrated system does, but, in fact, the logic engine and the knowledge base can serve as very so- phisticated screens for the physicians’ decisions. For instance, imagine that a patient with a history of sleep apnea is prescribed a narcotic to mitigate pain after surgery. Narcotics can cause peo- ple with sleep apnea to go into respira- tory arrest, but, as long as the history of sleep apnea is noted in the patient’s medical records, the system will alert the physician to that potential problem. It also takes into account the patient’s age, likely metabolism, probability of renal failure, maximum allowable life- time amounts of a chemotherapy agent, and hundreds of other factors.
The logic engine and knowledge base at Partners are used more during order entry than at any other time. But they are used increasingly during normal re- view of patient medical records as well. For example, the system alerts the physi- cian, as he or she reviews Mrs. Smith’s record, to follow up on her marginally abnormal mammogram or to recheck her cholesterol levels. In addition, it may remind a physician that a particular pa- tient should receive a call or schedule a follow-up appointment.
There are, of course, times when a physician isn’t treating a patient directly yet still needs to know that something has happened. For these times, Partners developed an event-detection system that alerts a physician when a hospi- talized patient’s monitored health indi- cators depart significantly from what is expected. The physician is notified
through a pager and can then visit the patient directly or call in a new treat- ment. Minor variations are routed to the nurses’ station, and the nurse can decide whether to call in the physician.
The power of knowledge-based order- entry, referral, computerized medical- record, and event-detection systems is that they operate in real time. Knowl- edge is brought to bear immediately without the physician having to seek it out. In some situations, physicians can consult with other experts in real time, via teleconferencing and other tech- nologies. Such practices are still in their early stages, but they show great prom- ise. For example, if a patient on Nan- tucket island experiences what his doc- tor suspects is a stroke, he needs to be diagnosed and treated within an hour or his chances for full recovery drop precipitously. By the time he is flown to Cape Cod Hospital, it might be too late. If a specialist in Boston, or for that mat- ter in Tel Aviv, can interview the patient over a videoconference screen, observe how he speaks and moves, and review scan results, the likelihood of effective treatment will go way up.
Partners has also assembled many other knowledge resources that are not accessible in real time but are valuable nonetheless. These sources are more extensive than what’s in the clinical- information database. However, they’re like traditional knowledge-management systems in that users need to seek them out. The organization’s on-line sources (collectively called The Handbook) in- clude on-line journals and databases, care protocols or guidelines for partic- ular diseases, interpretive digests pre- pared by Partners physicians, formu- laries of approved drugs and details on their use, and even on-line textbooks. All of these resources are accessible through an integrated intranet portal. It’s an unusually good set of resources, but they’re not different in kind from those that practitioners at other hospi- tals can consult. The Handbook is ac- cessed, across all Partners institutions, about 3,000 times a day. Contrast this with the 13,000 orders submitted a day at Brigham and Women’s alone; even
Just-in-Time Knowledge Management • BEST PRACTICE
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BEST PRACTICE • Just-in-Time Knowledge Management
though it’s invisible to the clinicians, the information embedded in the order- entry system is used far more inten- sively than The Handbook is.
While Partners’ embedded-knowledge program has been under development for more than a decade, it’s still not com- plete. The on-line order-entry system and related knowledge are only accessi- ble within the organization’s two flag- ship hospitals, Mass General and Brig- ham and Women’s. Medical knowledge has not yet been codified for all the dis- eases that Partners physicians treat. But the approach is clearly beneficial. A con- trolled study of the system’s impact on medication errors found that serious er- rors were reduced by 55%. When Part- ners experts established that a new drug was particularly beneficial for heart problems, orders for that drug increased
Embedded-knowledge initiatives should only be undertaken for truly critical knowledge work processes.
from 12% to 81%. When the system began recommending that a cancer drug be given fewer times per day, the percent of orders entered for the lower frequency changed from 6% to 75%. When the sys- tem began to remind physicians that pa- tients requiring bed rest also needed the blood thinner heparin, the frequency of prescriptions for that drug increased from 24% to 54%.
These improvements not only save lives, they also save money. For starters, the system now recommends cheaper as well as more effective drugs. Even more important, it helps prevent longer hospital stays and repeat tests that result from adverse drug events (ADE). That can save a facility large sums of money, since a 700-bed hospital will normally incur about $1 million per year in pre- ventable ADE costs. Order entry with em- bedded knowledge is still rare enough that U.S. insurers have not yet seen their costs go down, nor have national mal-
practice figures changed. However, Part- ners, which insures itself for malprac- tice, has some early data suggesting that malpractice reserves can be smaller be- cause of fewer drug-related claims.
Keys to Success
Developing a system like Partners’ isn’t easy – from either a technical or a man- agerial standpoint. Few off-the-shelf software packages used for knowledge- intensive business processes allow in- dividuals and organizations to embed their own knowledge into systems. Part- ners had to develop most of its systems from scratch, creating a complex infor- mation and technology infrastructure that pulled together the knowledge base and logic modules with an integrated patient-record system, a clinical-decision support system, an event-management system, an intranet portal, and several other system capabilities. Other hospi- tals have some or all of these capabili- ties, but Partners’ real-time knowledge approaches are undoubtedly at the cut- ting edge.
The technical underpinnings of an embedded-knowledge system are key, but just as important are the nontech- nical, managerial aspects required to keep the system running smoothly. Several of these aspects – each of which would be relevant to any organization seeking to bake knowledge into its work – are described below.
Support from the Best and Brightest.
Building a system like Partners’ is a chal- lenging IT project, to be sure. But then comes an even harder task: Convincing knowledge workers, no matter what en- vironment or field they’re in, to support the system and the new way of working. The growing concern over medical er- rors provided that motivation at Part- ners; absent a similar sense of pressing need, it probably wouldn’t have gotten off the ground.
An Expert and Up-to-Date Knowledge Base. If Partners’ clinical database in- cluded idiosyncratic, untested, or obso- lete knowledge, it would put patients – and Partners itself – at high risk. Thus, only clinicians at the top of their game can create and maintain the knowledge
repository. Partners has addressed this issue by forming several committees, and empowering existing ones, to iden- tify, refine, and update the knowledge used in each domain. For instance, the medication recommendations in the system come from drug therapy com- mittees. Teams of specialists design care protocols for particular diseases. And radiology utilization committees have developed logic to guide radiology test ordering. Participation in these groups is viewed as a prestigious activity, so busy physicians are willing to devote extra time to codifying the knowledge within their fields.
Prioritized Processes and Knowledge Domains. Since these initiatives are dif- ficult and expensive, they should only be undertaken for truly critical knowl- edge work processes. At Partners, it was relatively easy to identify which med- ical care processes were the most cru- cial, but important decisions still needed to be made about which disease do- mains and medical subprocesses to ad- dress – for example, ordering medica- tions versus referring a patient to a specialist – and in what order. Fields with many disease variations and multiple treatment protocols, such as oncology, are more difficult to include in the knowl- edge systems. In general, it’s preferable to develop systems in fields with low lev- els of ambiguity, a well-established ex- ternal knowledge base, and a relatively low number of possible choices facing the decision makers.
Final Decisions by the Experts. With high-end knowledge workers like physi- cians, it would be a mistake to remove them from the decision-making process; they might end up resenting or rejecting the system if it challenged their role – and with good reason. Because over- reliance on computerized knowledge can easily lead to mistakes, Partners’ sys- tem presents physicians with recom- mendations, not commands. The hope is that the physicians will combine their own knowledge with the system’s. Out of the 13,000 orders entered on an av- erage day by physicians at Brigham and Women’s, 386 are changed as a result of a computer suggestion. When med-
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harvard business review
Just-in-Time Knowledge Management • BEST PRACTICE
ication allergies or conflict warnings are generated, a third to a half of the or- ders are canceled. The hospital’s event- detection system generates more than 3,000 alerts per year; as a result of these alerts, treatments are changed 72% of the time – a sign that the hybrid human- computer knowledge system at Partners is working as it should.
A Culture of Measurement. In order to justify the time and money spent on an embedded-knowledge system, and to assess how well it’s working, an orga- nization needs to have a measurement- oriented culture. Partners has always had a strong measurement culture be- cause it is an academic medical center and because most of its senior clini- cians are also researchers. Its knowledge management approach has only fur- thered the emphasis on measurement. The tracking mechanisms within the order-entry system can detect whether the physicians use the knowledge and change their treatment decisions, which is the only way to know that the sys- tem is working. The measures are used as justifications and progress reporting tools for efforts to reengineer and con- tinuously improve care processes.
The Right Information and IT People.
Whenever knowledge technologies are applied to business problems, it’s tempt- ing to attribute any success to the tech- nology. But in the case of Partners’ sys- tem, and in many others we’ve seen, success is based mostly on the people
behind the technology. An IT organiza- tion that knows the business and can work closely with key executives and knowledge-rich professionals is impor- tant. A “back room” IT group could never successfully build a system of this type. Also important is a staff that is skilled in information management. In health care, this discipline is called med- ical informatics, and Partners has re- cruited leaders in this field. It has several medical informatics departments, in- cluding Clinical and Quality Analysis, Medical Imaging, Telemedicine, and Clinical Information Systems R&D. The leaders of each of these departments are doctors, but they also have advanced degrees in fields such as computer sci- ence, statistics, and medical informatics. •••
In general, it’s easier to embed knowl- edge into the work of less-skilled work- ers; the higher you go, the harder it gets. But organizations are gradually learning how to make the concept work at all levels. Customer service representatives without a great deal of technical skill now have highly scripted jobs. Many highly skilled reps at high-tech firms like Hewlett-Packard, Dell, and Xerox work with computer systems that rapidly sup- ply knowledge to help them resolve cus- tomers’ problems. Midlevel knowledge workers – programmers, engineers, de- signers – depend increasingly on knowl- edge repositories built into the tech- nology they use to do their jobs. GM’s
Vehicle Engineering Centers, for exam- ple, program information about the desirable dimensions of new vehicles and the parameters of existing compo- nents into the company’s computer- aided design systems so that car and truck designers can’t help but employ the knowledge.
Baking knowledge into the work pro- cesses of high-end professionals like physicians is relatively new. Such pro- fessionals are different from other know- ledge workers: They’re generally paid more and receive more intensive train- ing; they make decisions based largely on intuition and years of experience; they’ve historically enjoyed high levels of autonomy; they’re sufficiently power- ful that the organizations they work for are reluctant to tinker with their work processes; and, perhaps most important, they do most of their work away from a computer screen. All those factors make it harder to embed knowledge into their work processes. But the Partners exam- ple illustrates that it is indeed possible to inject knowledge directly and effec- tively into the work these professionals do, dramatically improving their per- formance. And for people like Dr. Gold- szer and his patients, such improve- ments can make all the difference.
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