Knowledge Management In Managed Healthcare

With the emergence of corporate hospital entities and complex core and non-core operations in healthcare sector, the role of knowledge management is bound to make a headway, say Prof B B Tandon, Dr Anil Kumar Angrish and Shiv Kumar Anand

For a knowledge-based society, knowledge-based economy, knowledge-based corporate entity and for a managed healthcare entity, knowledge management is indispensable. Corporate entities are building Knowledge Management (KM) systems and employing professionals in their knowledge centres, which are being managed by knowledge executives. A few companies even boast of appointing a Chief Knowledge Officer to manage knowledge in their concerns. It is visible that significance is being given to KM. With the emergence of corporate hospital entities and complex core and non-core operations in healthcare sector, the role of KM is bound to make headway.

Recently, Dr Anbumani Ramadoss, Union Minister for Health and Family Welfare, asked for revision of the curricula of medical colleges to make it more modern, besides holding examinations for medical practitioners after every five years for re-registration as is the case in many developed nations. Basically, it requires doctors to update their knowledge.

For all medical practitioners, a vast knowledge is available about their domain. More than 10,000 different diseases and syndromes, 3,000 medications, 1,100 laboratory tests are in use. Moreover, plenty of articles are added each year to the biomedical literature. In this way, it is quite difficult for a doctor to keep himself abreast of new knowledge in his field and at the same time perform his routine tasks.

This is not an end in itself. A number of studies have been conducted on medical errors. The Institute of Medicine, USA in the year 1999, in its repot titled 'To Err is Human', stated that more than 98,000 deaths each year are attributable to medical errors in the US. In India, we find various cases in routine such as patients having adverse reactions to drugs while under medical care, out of which, some reactions are life threatening. The underlying reason is inappropriate drug prescriptions. Not difficult to find are instances where common laboratory tests ordered by physicians are clinically unnecessary and prescriptions inappropriate.

A shocking statistical evidence is cited in a report released by the Nutritional Institute of America (NIA) in October 2003. The results of seven years of research reviewing thousands of studies conducted by the NIA show that medical errors (iatrogenic errors) are the number one cause of death and injury in the US.

According to NIA's report, over 7,84,000 people die annually due to medical mistakes. And over 2.2 million people are injured every year by prescription drugs alone and over 20 million unnecessary prescriptions for antibiotics are prescribed annually for viral infections.

If such alarming situation is of a country like the US, where regulations regarding healthcare are most stringent in the world, the condition of a developing country like India can only be imagined, where the pharma covigilance system in not even in the nascent stage.

The reasons attributed to such mistakes are many. A significant reason is that, clinicians are not able to track such massive amounts of complex information. So, knowledge workers cannot keep up with the knowledge being generated. Even though the failure to keep up may not result in deaths, but definitely it leads to lower chances of success in projects and products and wastage of resources.

In the last decade, the focus of KM was to establish employee networks and communities of practice, building of knowledge repositories in organisation and sharing of information. Still, the focus is to embed the knowledge into knowledge work and technology, which is used by knowledge workers to perform their jobs. However, this is time consuming and an expensive exercise, but still worth implementing.

Apply Information Technology

It is desirable for a hospital to link massive amounts of constantly-updated clinical knowledge to IT systems that support doctors' work processes. It will improve the quality of physicians' decision-making and hence improve the quality of patient care. However, what poses a major problem is, hospitals are not able to codify millions of facts and data points, which are used by doctors to make complex decisions about treatments. So, as a starting point, choose a narrow area; for example, target an essential work process such as physician order entry and a problem that was well documented, errors in drug prescriptions and lab-test ordering.

Drug interactions are relatively straightforward and easy to programme. This is central point as when doctors order tests, medications, or other forms of treatment, they are actually translating their judgements into actions. At this moment, outside knowledge is most valuable. And it is here that without the system, doctors would have no easy way to access others' knowledge in real time.

Order entry system increases efficiency and safeguards against errors due to poorly-written orders. It allows physicians easy access to massive amounts of up-to-date medical knowledge (even though they are doing their daily work). Finally, it forces physicians to engage with queries or recommendations (even though they can override the system's recommendations).

In this way, order entry is a key work process. Further, the approach should be built on a set of integrated information systems which physicians can use to manage patient care. These all draw from a single database of clinical information and use a common logic engine that runs physicians' orders through a series of checks and decision rules.

For Instance: A patient has a serious infection and the doctor decides to treat it with some drug, say cefazoline. After logging on to the computer to order the drug, the system checks patient' medical records and if it finds that patient has a history of immediate type of hypersensitivity reaction with penicillin then it will immediately alert the doctor about the possible side effects. This is similar to the pop-up message shown by a computer while downloading files from the net — this file may harm your system would you like to continue — though the ultimate decision is left in the hands of the decision-maker. If positive effects from the prescription overweigh negative effects, the physician goes on with his decision after 'risk-benefit analysis' (remember the case with glucocorticoids that has major side effects but even then, are prescribed due to their indispensable ability to save life of patients in extreme emergencies).

Similarly, when doctors order test for a patient, the system may tell that such a test is useful or not in addressing the symptoms identified or it has already been performed on patient for a number of times and a retest will not serve any purpose. This may be useful during review of patient medical records as well as follow-up appointment.

The key success factor of knowledge-based order entry, referral, computerised medical record and event detection systems is its real time application. Moreover, physicians can consult other experts in real time through teleconferencing and other technologies. Even through video conference screens, doctors can observe a patients' speech and moves and review scan results, the likelihood of effective treatment will go way up. Few months ago, PGIMER, Chandigarh has announced the telemedicine project that would be linking civil hospitals of Ajnala, Patiala and Dassua to the PGIMER. So, the patients from these far-flung areas, not having access to specialty medical facilities can now have an expert advice from PGI doctors without actually visiting the place. Indirectly, doctors can seek advice from experts in their domain in real time.

This means that advice about patient's diagnosis and treatment can be given by reviewing test reports, all diagnostic tests, X-rays, CT scans, pathology slides et al, can be transmitted to PGI for consultation. This initiative will indeed reduce the patient load from the doctors and will allow doctors devote more time for high-level research, for which these kind of high-level institutes like AIIMS, PGI etc have been established.

Knowledge Repositories

There are other knowledge resources which are not otherwise accessible in real time even though they are valuable. Knowledge repository in hospitals should include online journals and databases, care protocols or guidelines for particular diseases, interpretive digests prepared by physicians, formularies of approved drugs and details on their use, and even online textbooks. An integrated intranet portal can make these resources accessible. Practitioners can share this set of resources on mutually-agreed terms.

Benefits Of Knowledge Repositories

• Recommendation of cheaper and more effective drugs.
• Helps prevent longer hospital stays.
• Prevents repeat tests that result from adverse drug events.
• Lowers malpractice reserves (phenomenon prevalent in developed countries) on account of fewer drug-related claims.

Critical Aspects

They are either technical or non-technical.

Technical Aspects: Development of such a system is not easy from either a technical or a managerial standpoint. Systems allowing individuals and organisations to embed their own knowledge are not available. Hospital entities have to develop most of its systems from scratch, which includes modules such as an integrated patient-record system, a clinical decision support system, an event management system, an intranet portal and several other system capabilities.

Non-technical Aspects: This includes managerial and few other aspects. The harder task is to convince knowledge workers about the utility of the system. It is because their willingness to support the system and new way of working that can make or mar all other efforts. Up-to-date clinical database is another pre-requisite. Else, it would put patients as well as hospitals at high risk. To address this issue, different committees can be formed and empowered to identify, refine and update knowledge used in each domain. Overall, a step-by-step approach is required. KM initiatives should be undertaken for truly critical knowledge work processes because of cost and difficulty involved. At the same time, preference should be given to develop systems in fields, which have low levels of ambiguity, a well-established external knowledge base and a relatively low number of possible choices facing the decision-makers.

Besides, it is easier to embed knowledge into the work of less-skilled workers; the higher you go, the harder it gets. Middle-level knowledge workers such as programmers, engineers, designers depend increasingly on knowledge repositories built into the technology they use to do their jobs. For high-end knowledge workers, ie doctors/physicians, the spirit behind integrated systems is that the physicians should combine their own knowledge with that of the system. Both are supportive and not alternative to each other. Following are certain unique features of these high-end knowledge workers which are clear pointers in this direction:

(i) They are generally paid more and receive more intensive training.

(ii) They make decisions based largely on intuition and years of experience.

(iii) They have historically enjoyed high levels of autonomy.

(iv) They are sufficiently powerful that the organisations they work for are reluctant to tinker with their work processes.

(v) They do most of their work away from a computer screen.

To put it straight, doctors/physicians are high-end knowledge workers, so it would be a mistake to remove them from the decision-making process. Otherwise physicians/doctors might end up resenting or rejecting the system altogether if it challenges their role. If the system generates conflict warnings then orders should be cancelled as per warning; and if the hospital's event-detection system generates a given number of alerts during a given period then treatments should be changed as per requirements. It will indicate that hybrid human-computer knowledge system is working as it is expected.

Another non-technical aspect that has significant bearing on overall KM initiatives is a measurement-oriented culture. It lays emphasis on output of a given system to justify the time and money spent on an embedded knowledge system. The tracking mechanisms help in detecting whether physicians/doctors use the knowledge and also show change in treatment decisions, if any. This ensures that the system is working effectively. Parameters for measurement can be fixed beforehand and then progress-reporting tools are used to improve existing processes.

Then there is interaction and co-ordination of 'back office' and 'front end'. The reason is that technology itself does not ensure success. Persons working behind it have to work with staff which is skilled in information management, besides doctors who are high-end knowledge workers. In healthcare sector, the task is entrusted to people skilled in information management and discipline is called medical informatics. It can have other medical informatics departments such as clinical and quality analysis, medical imaging, telemedicine and clinical information systems R&D.

To put it in perspective, with the growing complexity in the human living patterns, the nature and number of diseases are increasing significantly, while the drug discovery and development is not able to keep pace in providing a cure for them. Also is increasing the complexity of information regarding these diseases and their management.

In order to safeguard the interest of patient and provide the best of healthcare, need is to design and adopt a system, which can streamline available information and assist high-end knowledge workers for continuously upgrading the practice of medicine and provide the best and the safest medical care to patients.

Tandon is former Dean and Chairman, University Business School, Punjab University, Chandigarh; Dr Angrish is Senior Teaching and Research Associate, Department of Pharmaceutical Management, NIPER, Mohali, Punjab; and Anand is Assistant Professor and Co-ordinator, Graduate and Postgraduate programmes in Information Technology, GJIMT, Mohali, Punjab.