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J Patient Saf
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J Patient Saf
Horvath et al
DESCRIPTION OF CASE
At DUHS, we applied a BI strategy to share ADE-S data
with patient safety ofcers and QI specialists. This approach
would allow standardization of the user interface to accommodate customers with varying levels of computer experience. We
sought to integrate ADE-S with other databases within the
DUHS data warehouse to enable aggregate reporting functionality using COGNOS BI 8.2 (Fig. 1). This platform enables
data querying, reporting, analysis, and event management
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under a single integrated architecture. We chose COGNOS because several data warehouse team members had extensive experience using this platform. Our end goal was to develop a set
of dynamic reports where the user could navigate from aggregate ADE trends to detailed event information. Because of
differing safety concerns between patient care areas, we also
desired reports that would subset aggregate rates into userchosen categories, including nursing station, event severity, and
drug class. We assigned report creation and maintenance duties
to the existing ADE-S research analyst, who had partial knowledge of both the clinical and technical realms as well as being
skilled in analytics. The report customers were to be QI leaders
at the hospital and health system levels that are charged with
developing patient safety quality initiatives.
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J Patient Saf
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IMPLEMENTATION OF BI REPORTING
Because nearly all end users of the BI reporting portal
were clinicians, the design goal was to enable execution of reports without needing knowledge of SQL scripting or the underlying database schema. To this end, COGNOS required
data organized into packages, which are groups of metadata
logically linked as dened by the current business problem.
For this project, ADE-S relevant information was organized
into 4 core packages: adverse event surveillance, patient, encounter, and census. The patient package included data tied
to anindividuals medical record number (i.e., name and demographics), but not to a hospital visit. The encounter package data was specic to a patient stay at 1 of the 3 hospitals and
included details on the admission, discharge, and clinical services. Census data were dened as admissions and inpatient
service days on a per nursing station, per day level.
Adverse drug event surveillance reports were created
using the COGNOS Report Studio web tool. From a technical
perspective, a COGNOS report is a specied collection of
SQL database queries, prompts, layouts, and styles arranged
together during the design phase to create interactive charts and
tables. Reports were created by combining the data elds from
different packages through a drag-and-drop web interface. The
combination of data elds as built by the report author creates
a series of SQL commands invisible to the end user. This
SQL script queries the data warehouse when the report is
run. Reports were constructed with maximal exibility in order to generate a wide variety of results dependent on the
prompt selections of the end user. For example, COGNOS report execution creates a report view, which displays a static instance of data based on the prompt choices (i.e., nursing station,
event severity, drug class) as selected by the user. Neither report
DISCUSSION
The immediate benet of BI implementation was a reduction in the research analysts workload, which allowed that
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J Patient Saf
Horvath et al
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TABLE 1. Business Intelligence Reports Developed to Display Aggregate Adverse Drug Event Surveillance (ADE-S) Rates
Report Description
ADE list reportV
event details
Prompts
Hospital
Event date
Event location (nursing station)
Surveillance drug rule*
Surveillance drug category*
Event causality*
Event severity*
Medical record number*
Duke employee ID
Hospital
Event date
Report Output
Drill Downs
Hospital
Event date
time to be allocated to additional patient safety projects. Previously, a research analyst created a set of twelve reports per
hospital to plot monthly ADE rates for high-risk drug categories. This exercise took approximately 4 to 6 hours each month
per DUHS hospital. This highly manual, labor-intensive process
created many opportunities for errors meaning double and
triple data checks were required to ensure reporting integrity.
However, using a BI application, patient safety ofcers could
now retrieve each of these reports themselves in less than 10
minutes for 2 years of trended data. In addition, user-driven
prompts on the front end of the reports allowed rapid change
of a reports parameters, such as changing the severity level of
ADEs included in the aggregate rate graph. Similarly, the ADE
list report offers access to highly customizable ADE extracts
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J Patient Saf
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FIGURE 2. Prompt page for ADE-S reporting. Variations of this prompt page are present in all core reports. These prompt
selections create hidden SQL lters in the report architecture which allow users to obtain aggregate trending reports tailored to
their QI needs.
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Horvath et al
J Patient Saf
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FIGURE 3. Adverse drug event surveillance aggregate trending reports. Although a large number of reports have been developed,
most are variations of 2 core reports: ADE rates by month per unit and ADE rates by month per drug category. All reports begin with
a prompt screen allowing selection of date range, hospital, nursing station, drug category, and event severity. When the ADE rates
by month, per drug category report is run, the next 4 successive web pages show a bar chart of ADEs per 100 admissions, a table of
ADEs per 100 admissions, a chart of ADEs per 1000 patient days (A), and a table of ADEs per 1000 patient days (B). The ADE rates by
month, per nursing station report brings up 4 similar web pages (C). Clicking on the graphics or links launches a new window
giving a list report of all ADEs that compose the bars or table cells.
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reports would not run successfully without precise browser security settings. Each workstation accessing the portal had to be
individually congured for staff members, requiring an unanticipated amount of time from technical personnel. Finally, as
QI ofcers explored the tool, they desired to trend ADE rates
by the specic medication involved, not just the drug category. The ADE-S source system treats the medication eld as
free text meaning these data are plagued with spelling errors,
brand names, and inconsistent medication codes. Given that
DUHS has yet to choose standardized medication taxonomy
to link drug information from disparate clinical system vocabularies within the data warehouse, we left development and
cleanup of the ADE-S medication dimension to a future enhancement phase.
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J Patient Saf
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dedicated employees, a research analyst and a pharmacist, translate between clinical staff familiar with the ADE-S operational
system and the technical staff that maintain the DUHS data
warehouse. This model ensured that solutions were approached
in a manner consistent with clinician needs. Because of personnel issues, it is common that no one can be allocated to
these positions as they require meeting attendance, availability
for consultation, and quality assurance duties. However, without
these individuals, critical design aws may not have been
corrected before full implementation. We would not embark on
any future project that seeks to warehouse the information from
clinical operations without allocating such resources.
Second, we found that although the needs of the ADE-S
operational system differed from those of the warehoused data,
the design of both systems must complement each other. For
example, a pharmacist reviewer may enter the ADE-S operational system and update a previously nalized evaluation at
any time. As a result, the data warehouse ETL must be sophisticated enough to detect updates, not just the presence of
new ADE-S records. Similarly, ETL development made us realize
that aspects of the operational system require standardization to
ensure data cleanliness. For example, certain data elds could be
manually overtyped by pharmacist reviewers in the ADE-S
operational web application, which creates the potential for
incorporation of stray keystrokes. To alleviate future data integrity
infringements, we write protected those elds during development.
Based on the impressions from this case study, we hope
to perform formal usability studies of the BI reporting methods in the future as to maximize clinician acceptance. This will
help us to understand how the reports should be ideally structured as well as which method of user access is the best. We
expect that complementary methods of report access will be
needed to serve all relevant care providers. At that time, we
will also revisit the issue as to whether all staff members involved in frontline care should be able to see aggregate ADE
rates. This would require substantial redesign of the existing
security model; however, such a project is already underway
to serve the voluntary Safety Reporting System which provides
1 method of access to ADE-S reports.
To our knowledge, DUHS has the only ADE surveillance
system in the United States that functions in both community
hospitals and academic medical centers in support of
performance improvement metrics and QI initiatives. Those
seeking to implement any set of ADE detection methodologies
should also ensure that strategic information technology plans
are in place to share the resulting data with QI stakeholders.
Our hope is that other health systems will similarly report their
experiences in the management, sharing, and analysis of large
clinical data sets within their organizations. Biomedical
informatics, human factors engineers, and information technology staff should be encouraged to take a leading role in
those publications as well.
ACKNOWLEDGMENTS
The authors thank the data warehouse group at Duke
Health Technology Solutions for technical support in developing
the COGNOS reporting portal.
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