Redefining Quality of Patient Care and Patient Safety using GIS

By William F. Davenhall

Harnessing the power of geography to improve outcomes
Historically, patient safety has been viewed as actions that minimize a patient's exposure to unnecessary risk, keeping patients from falling or reducing medication dosage errors while in the healthcare environment for example.  However, the Joint Commission of Accreditation of Healthcare Organizations (JCAHO), a major quality of care organization, recently suggested that patient safety extends beyond the walls of the hospital and into the community.  Experts on clinical outcomes have long recognized that geography plays a critical role in explaining different medical outcomes.  This new notion of patient safety presents interesting questions and new opportunities for geographic information system (GIS) technology.

A healthcare organization can develop a community-based approach to quality care and patient safety beyond hospital walls.  Patient safety and care quality do not end with patient discharge.  Rather, the highest quality of medical care and patient safety is a continuum that spans both time and place.

We hope to stimulate and challenge the reader to explore the persistent and unmistakable convergence of two powerful forces-human health and environmental conditions.  The value of using spatial and geographic intelligence to deliver quality healthcare, as well as a new analytical framework within which to think about lifelong patient safety, is tremendously important.  Geography is intrinsically tied to medical destiny; it is tied to patients receiving the highest quality care in the safest environment.

Why Improve Quality Care and Patient Safety Outside Hospital Walls?
Hospitals and clinics are places where patients are examined and treated.  It is within these walls that many patients receive unexpected outcomes created by unsafe conditions or unskilled practitioners.  Rarely have institutional providers or practitioners extended their responsibility for patient safety beyond the facilities' walls.  Typically, a healthcare provider is insured against malpractice and general liability for actions in which they are directly responsible.

However, does this system offer the best quality care and safety to patients and the community?  The often published and heralded Institute of Medicine Study estimates that at least 96,000 patients die unnecessarily each year in U.S.hospitals, yet masks a quiet crisis-the equally unnecessary deaths every year of hundreds of thousands of Americans suffering from chronic conditions that could have been prevented or better managed.

Viewing patient safety outside healthcare facility walls will require health organizations to reexamine their missions and operating procedures.  This concept has the potential to profoundly affect how healthcare services are organized, delivered, and evaluated.  Two major factors must be well understood before this new view can be successfully operationalized:  (1) definition of exactly when patient safety begins, and (2) definition of indicators of quality care that are able to transcend time and place.

Geography as Medical Destiny
The explicit goal of healthcare is to produce a quality product with favorable and expected outcomes and deliver it in such a way that a patient's safety is not compromised.  When a patient presents himself or herself to a healthcare practitioner, the health provider's ability to produce high-quality results has already been compromised.  After all, the patient has been getting sick for an undetermined period of time.  In fact, the cause of a sickness may actually be the result of historical conditions and factors that cannot be undone or reversed.  If we are expected to provide patient safety within the context of the larger community, we must be able to evaluate a wide range of historical and temporal information that is both clinically relevant as well as place and time sensitive.

Major healthcare accreditation and oversight bodies, such as JCAHO, have expressed interest in redefining the geographic or spatial scope of patient safety, encouraging healthcare providers to consider the value of integrating internally generated healthcare information with externally available population health information.  Principal drivers for such a redefinition of quality care and patient safety include the impact of unintentional toxic exposures, compromised environmental conditions, unexpected situational dangers, untoward outcomes, medical misadventures (during or after clinical care), and the lack of timely logistical information for dispatching health professionals and medical supplies.

Research Regarding the Impact of Location
Research regarding the impact of geography on medical destiny has bolstered our understanding of location's long-term effects on various aspects of health and safety.  The newest approach redefines location as where the patient is at all times.  Similar to the technology used by court systems to track individuals with ankle and wrist bracelets or LoJack to locate stolen cars, researchers are equipping patients with global positioning system (GPS) and ambient air quality monitoring technology.  Inside or outside facility walls, the ability to monitor and measure various environmental and clinical inputs is incredible.

For example, proposed research funded by the Environmental Protection Agency (EPA) at the Loma Linda University School of Public Health provides a glimpse of these capabilities.  The proposed study will focus on the impact of ambient air quality on cardiovascular disease.  In order to record specific air quality measurements and to extract exact time and place information, subjects will wear a small device that records the quality of the surrounding air.  Patients' geographic movements will also be tracked.  It is likely that other types of personal health measuring devices that can be mounted, installed, or swallowed will be coming into mainstream research and clinical trials in the not too distant future.

These new approaches to health monitoring come on the heels of substantial literature that describes the impact of geographic location on health.  For example, numerous studies demonstrate the contribution of limited sunlight exposure and subsequent vitamin D deficiencies to cancer, diabetes, hypertension, and osteoporosis.  Such studies focus on locations far from the equator, as geographic location is the basis for sunlight exposure.

The importance of place in medicine is becoming increasingly better understood.  The seminal work of Dartmouth physician researcher, John Wennberg, M.D., has demonstrated that geography alone is a good predictor of medical outcomes.  Wennberg's research demonstrates that when all clinical and demographic factors are held constant, geography can explain the observed differences in both outcomes and making the correct diagnosis.
What does this say about where a person came from or has been?  Could geographical locations and the duration of time spent in each location help to explain present health status and conditions?  In order to provide the best possible patient outcomes, it is important for healthcare organizations to pay close attention to geographic location.

When Does Patient Safety and Quality Care Begin?
Defining the moment that patient safety and quality care begin can help us understand what type of data we need to collect, monitor, and measure as well as what type of information system we will need to organize and analyze this data.  When does the safety and care process begin?  When does it end?  Presently, most healthcare providers create artificial boundaries that constrain their exposure to potential risks and liabilities.

Consider this situation.  You enter a hospital with a life threatening disorder and, in response, the hospital monitors your blood pressure every six hours and your temperature every 12 hours for five days.  The hospital then discharges you, taking you to a car by wheelchair.  When you arrive home, you climb two flights of stairs daily with no assistance, and no one takes your blood pressure or temperature for two weeks.  When did quality care and patient safety begin?  When did it end?

Often the concepts of patient safety and quality of care are used with the assumption that exactly when a person takes on the role of patient is quite straightforward.  But think about how you would define the moment you became a patient-has this moment ever stopped?

Suddenly it becomes apparent that when you became a patient may represent a continuum rather than an event.  The healthcare system currently defines a patient's use of the healthcare system as individual events.  Such a perspective is reflected in the industry's terminology, referring to interactions with hospitals and doctors as "encounters," "events," "admissions," or "discharges."  Healthcare providers tend to view these transactions as separate events or, at best, events related to an episode of care.  However, when viewed from a patient's perspective, it becomes difficult to say when the concept of quality of care and patient safety begins or ends.  As patients, we often know when we do not receive what we think of as quality care, and we certainly are well aware of major failures of the safety system when we learn about accidental deaths.  Patients view all this as a continuum, in which everything is related to everything else, in direct opposition to that of the typical healthcare provider.

Implication to Healthcare Information System Design
The world's healthcare information system has been built around the functions that healthcare providers must perform either for clinical or administrative documentation, usually to create a record that will protect the institution and its participants from lawsuits, aid medical researchers, and provide a record of who did what to whom and for how much.  However, when care is rendered, very little of this health information is used to directly protect the safety of a patient either within or outside caregiver walls.  By contrast, there is a considerable number of real-time laboratory, drug dosing, and administrative procedures that produce automatic warnings or report "panic" values when patients' lives are threatened.

Hospitals are notorious for their underutilization of the entire medical history of a patient in their care, a shortcoming that is largely the result of an intense focus on the episode at hand.  While other parts of the healthcare system are held accountable for providing a continuum of care, in most cases this continuum is poorly served by the health information systems designed primarily for episodic care record keeping and legal documentation.

Due to these factors, we can expect to see greater interest in creating a comprehensive and integrated personal health information system that considers the continuous, time, and spatially sensitive nature of health and disease, especially in the wake of the Severe Acute Respiratory Syndrome (SARS) epidemic.

The Healthcare Industry Is Aggressively Adopting GIS

There is sufficient evidence that health organizations see the business value in geographic information, and that hospitals, as well as all other stakeholders in healthcare, are increasingly using GIS.  Here are some ways that GIS is being deployed within the healthcare system today.

GIS is helping healthcare organizations improve service delivery through locational analysis, conducting smarter planning, making more effective choices for distribution or deployment of resources, improving service accessibility, and accurately collecting the spatial metrics of the system such as defining service areas, response times, bed availability, and surge capacities.

Hospitals have built GIS into their admission, discharge, and transfer (ADT) systems to improve the timeliness of the admitting process and deploy internal resources more efficiently and with greater accountability.  This same system has the ability to monitor bed surge capacity for disasters or epidemics in real time and provide hospital management with easily accessible command center information.

Managed healthcare organizations use GIS to quantify geographic disparities in disease outcomes and disease management practices.  Clinicians use GIS to better understand the demographic and utilization characteristics that create their clinical imperatives.

With the advent of the Internet, the wider use of GIS by health and human service organizations is allowing case managers to help clients comply with service referrals and deliver on accountability promises.

  Medical researchers are using GIS to aid in diagnosis and treatment.  Enhancing and measuring medical images is perhaps the area of greatest promise.  Providing spatial "eyes" to surgeons and radiologists will represent significant advances in understanding the relevance of spatial location to human anatomy.

  Health ministries are using GIS to establish national command centers that track infectious disease and monitor events that could affect the capacity or readiness of the entire healthcare system.  GIS is used to orchestrate the movement of national drug stockpiles and deploy scarce medical resources during emergencies and threats of danger to communities.

SARS:  The Need for Better Time and Place Information
The near global epidemic conditions of SARS made a convincing case for using exact place and time knowledge in understanding and controlling the spread of disease.  In the absence of this knowledge, every country's healthcare system and ability to keep its quality and safety promise was seriously compromised.

What information system presently installed in any major hospital in any nation was ready to protect its patients, staff, and visitors from a spreading pathogen?  Have you thought about what type of information you would need if smallpox appeared in your emergency department?  Would you be able to accurately locate every physician, patient, employee, and visitor to your facility for the past 24 hours?

GIS offers a new approach for many healthcare information professionals.  A decade ago I wrote that about 80 percent of all healthcare transactions had significant geographic relevancy; today I believe it is closer to 100 percent.

In the very near future, I believe you will not be able to think about any major healthcare reform or initiative without also taking time and place into consideration.  GIS, I am convinced, will certainly be a critical technology in the much-needed transformation of healthcare information.

About the Author
Born and educated in the United States, Bill Davenhall has worked in the health and human service field since 1974, during which time he has directed many different initiatives that involve the progressive use of information systems within hospitals and human service organizations.  Davenhall is a frequent speaker and writer and is well known as one of the leading advocates for the use of GIS to help solve some of the greatest challenges in health.  He earned a master's degree from the University of Kentucky in 1974.

Davenhall is global manager of ESRI's Health and Human Service Solutions Group at its headquarters in Redlands, California.  Founded in 1969 and presently the world's leading GIS software vendor, ESRI serves more than 300,000 clients.  The health and human services solutions sector is a community of more than 5,000 licensed users worldwide.  ESRI markets and supports its software through 90 international distributors and 2,700 employees worldwide.

Published Thursday, August 21st, 2003

Written by William F. Davenhall

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