Introduction by Croakey: The Cairns hearing of the Royal Commission into Aged Care Quality and Safety wraps up today, having heard from a roundtable of chefs, earlier in the week, that the quality of food served to aged care residents varies markedly from facility to facility and is sometimes very poor.
Celebrity chef, Maggie Beer, observed that a modestly increased investment, staff training, and care with menus would lift standards, and that appetising food was surely something residents deserved.
Uneven and often substandard care has been a recurring theme in the hearings so far, and it is disturbing that poor practice has flourished undetected.
The author of the post below, who gave evidence at the Royal Commission’s Darwin hearing last week, says appropriate use and linkage of routinely collected data could shed much needed light on common, systemic problems, such as prescribing errors, medication misuse, and neglected medical issues.
Professor Johanna Westbrook is the director of the Centre for Health Systems and Safety Research at the Australian Institute of Health Innovation.
Below she explains how “harnessing the enormous power of informatics” to create systems that use the data often already at hand, could make a difference in the individual lives of older Australians and their carers.
Johanna Westbrook writes:
Unlike the harrowing personal stories from inside our aged care facilities, my recent appearance at the Royal Commission into Aged Care Quality and Safety was not the stuff of headlines.
However, the opportunity to discuss the causes of systemic failures that lead to sub-standard care, and possible options to address these, was a critical step towards preventing future tragedies and improving the quality of life for many older Australians.
My focus was on the power of ICT (information and communication technologies) to alert us to what is going wrong, where and why. Application of data linkage and analytics, to routine data collected about the treatment and care of older clients held in existing electronic record systems, can provide valuable information to identify quality and safety issues.
Such information is urgently needed to better direct our efforts and to better design our aged care services.
This is not the kind of aspirational statement that requires a blank cheque and lengthy timeframes for implementation. The technologies and capabilities we need are already operating effectively in other sectors and can, with sufficient will, investment and incentives, be applied just as usefully to improve aged care.
Australia’s aged care sector – data rich but knowledge poor
The first step, though, is understanding Australia’s aged care sector as it is. As a healthcare systems researcher, my own work initially focused on how information technologies can impact quality and safety in acute clinical settings. But, realising how little attention has been paid to aged care delivery for our vulnerable elderly, my team of 40 researchers at Macquarie University has since undertaken numerous studies with aged care at their heart.
We’ve found that Australia’s aged care sector is immensely data rich, but knowledge poor. That is, although huge volumes of information are routinely collected and recorded – often describing in detail multiple aspects of every aged care client – most of it is never looked at again.
Much of this potentially useful data remains in silos, often as a mix of paper and electronic files. These records are rarely integrated to reveal sector-wide patterns or challenges, nor used locally to help providers and staff to coordinate, monitor and enhance care.
Challenges and opportunities in medication management
Take, for example, problems and errors associated with medication management, the most common complaint across residential aged care facilities. Our research in hospitals has revealed that electronic medication management systems can reduce prescribing errors by more than 50%, as well as significantly reducing the severity of medication errors that do occur.
No other intervention has ever produced such improvements in medication safety; one of the most intransigent barriers to safer, better quality healthcare.
By contrast, our aged care research, and that of others, has revealed a fragmented medication management process, often with poor coordination between all those involved, from prescribing GPs to dispensing pharmacists and the registered nurses and carers administering medications. Mixed communication methods, like phone, fax and paper – and the lack of centralised, accessible electronic records – means information is constantly at risk of being delayed, mis-communicated or lost.
Our 2017 study* comparing medication records for residents of aged care facilities with the records of their prescribing GP found an average of 9.97 discrepancies per resident. The most frequent discrepancy was a medication listed on a resident’s chart at the aged care facility but not listed with the same resident’s GP (34.9% of discrepancies), increasing the risk of unintended overprescribing or adverse drug interactions.
Picking up problems and variations
More specific questions can also be answered by drilling down into the data using integrated electronic records. The apparent overuse of antipsychotic drugs in aged care facilities to “calm” or sedate residents who do not have a relevant mental health condition is very much on the Royal Commission’s radar.
Working with some of Australia’s largest aged care providers, we used routinely collected medication data from 71 Australian facilities to build a useful picture of medication use across all these facilities to highlight potential areas of unexpected variation, including in rates of antipsychotic drugs.
The data showed variations in the use of antipsychotic drugs, which could be partly explained by the different profiles of residents in different facilities (these medications are right for some residents). But, the reasons for high rates of use of antipsychotics in some facilities were less clear, flagging the need for further checks.
With siloed data, medication practices remain opaque, but well integrated electronic data can tell us where to focus our attention and, if necessary, to institute changes. By linking residential aged care facility datasets we have been able to start to investigate issues of appropriate medication – for example, the extent to which residents with documented osteoporosis receive osteoporosis medications, and the proportion of residents with dementia who receive antidementia medications.
Pressure injuries, too, are a key measure of the quality of aged care. They are largely preventable, excruciatingly painful and costly to manage. Using pressure injury data, recorded as part of routine day-to-day practice, from 60 Australian aged care facilities, we were able to calculate rates, severity and location of pressure injuries.
We demonstrated trends in pressure injuries over time and by facilities, and showed that 14% of aged care facilities had persistently higher rates of pressure injuries than would be expected, based on the profile of their residents (for example taking into account residents with conditions such as diabetes which place them at greater risk of pressure injuries); a good reason for taking a closer look.
A dataset fit for purpose
The quality of data in these systems may be called out as not reliable enough to form the basis for national indicators, but these are the data that staff rely upon to provide care to clients. Investing in improved quality of health record data is vital to supporting high quality care for clients. These same data can be used for multiple purposes, to monitor care across facilities, and the sector.
Investing in improving the quality and accessibility of the data in these electronic systems should be a higher priority than setting up stand-alone resource-intensive auditing processes.
In community aged care, our team has used existing information systems to show that providing care for older people in the community is effective in significantly delaying entry to a residential aged care facility. This is an outcome older people seek, and which costs less than providing full-time residential care.
By embedding new quality of life measures as a standard part of clients’ assessments, we have shown how supporting older people in the community can improve and maintain their quality of life. Such results should inform policy decisions about whether to provide more community care services to meet the needs of the 130,000 older people approved, but waiting, for such services. We need more evidence-based aged care policy.
Harnessing unrealised potential
While the last decade has seen a substantial uptake of electronic data systems by the aged care sector, it is frustrating that the potential of these systems to increase the efficiency, usability and transparency of aged care information and provide a mechanism for improvements in the quality and outcomes of care still remains largely unrealised.
It was heartening, then, to be asked by Commissioner Lynelle Briggs AO whether a concerted effort to introduce effective interlinked electronic systems across the aged care sector could be achieved reasonably quickly. My answer was a qualified yes. Qualified, not because of any technical limitation, but a range of other challenges.
So many aged care information management systems are designed for supporting administration or financial functions, and not care quality and safety. IT vendors need to refocus their efforts to design integrated systems which support the unique characteristics of the hard-working aged care workforce.
Harnessing the enormous power of informatics can make a difference. Computers are excellent at seeing patterns in siloed pieces of information that humans may miss. Using predictive analytics, which work in the back-end of systems, can alert carers to those older people in need of greater attention. Significant culture change is also required, with greater sharing and transparency of information with clients and the community.
My team’s vision is simple: a visual electronic dashboard to provide decision support to clients and carers, which also supports the monitoring of care outcomes. Whatever the next generation of systems look like, importantly, we have good research evidence to show that integrating and utilising existing, routine electronic data more effectively can simultaneously drive improvements in the quality and safety of aged care and reduce the administrative burden on hard pressed staff.
* Verdult C JB. (2019) General practice and nursing home medication concordance study: A study exploring medication discrepancies between nursing homes and general practice. Master Thesis Universiteit Leiden.
Professor Johanna Westbrook is Director of the Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University. On Twitter @JWestbrook91