MIT

Looking for a way of evaluating his own performance as a surgeon, Dr. David Thomas examined various quality assurance software packages. Disappointed with his choices, Thomas joined programmer Paul Whitby to establish Medical Information Technology, Inc., or MIT. Using 4th Dimension, the company created a flexible database application, now running in five hospitals in the United Kingdom, which helps doctors practice quality assurance.

Objectively Evaluating Performance

The most important function of the database is to objectively evaluate physicians' performance and procedure success."The whole point of quality assurance is to review your results, make modifications and then review those modifications. It's a continuous circle of review, modify, review to see if your modifications have an effect on your performance, explains Thomas.

Before designing the database, Thomas had no objective way of evaluating his performance. Comparing his success rate against other surgeons' or even comparing the success rate of certain procedures was nearly impossible."You can't do quality assurance unless you've got a database with which to compare performance," notes Thomas.

In the hospital, the only accurate record of operations was a large book located in the operating room. To review operation results, surgeons had to scan through hundreds of pages in the book to locate particular operations or patients. No uniform method of reporting operations existed, and often crucial information such as complications, patient's health before the operation and patient's length of stay was omitted. Occasionally, incorrect patient numbers or information had been entered, making research difficult.

4th Dimension as a Reference

To perform quality assurance with the 4th Dimension database, surgeons and secretaries enter information into the computer, including patient demographics, complication factors, mortality rates, types of operations performed and average length of stay in the hospital.

The database automatically codes doctors' diagnoses and patients' illnesses according to international medical coding standards."When we compare what people do in other parts of the country and world, we need an international classification of the disease," explains Thomas."You have to have a precise code to compare your results with somebody else's."

The comprehensive coding system in 4th Dimension allows users to specify exact details about the problem and grade a patient's health before an operation. Some diseases have multiple codes, all of which apply to different but pertinent conditions. For example, appendicitis has approximately ten different codes; an appendix might be acutely inflamed or perforated, and both are coded differently. After the user chooses appendicitis, the database lists all ten possibilities and codes the user's choice accordingly. The medical code library is over 28 MB in size.

Currently, MIT's database is single-user, but the company is developing a multi-user application with 4D Server which will allow doctors to share patient data throughout the hospital. In fact, in a Belfast, Ireland hospital, 4th Dimension sends information to the hospital VAX so all departments in the hospital can use the same data.

The Belfast hospital is just one example of how the database can be tailored to fulfill the exact needs of each doctor and hospital. Menu bars can be customized to contain any menu items specified by a physician, and 4D Write mail-merge letters, complete with graphics and hospital logos, can be printed."We tried to make the program customizable so someone starts with the basic program and customizes it to their own use," states Thomas.

Doctors can write personalized mail-merge discharge letters and report summaries with the 4D Write word processor. Many doctors use pre-written templates for letters discussing common operations. Doctors can also perform any type of data analysis with the 4D Calc spreadsheet.

The database, which is password protected at various levels, is easy for new users to learn. It takes approximately two hours to train new users."It's that easy," states Thomas.

Improving Performance

To evaluate performance, doctors often print reports from database information and train their staff according to the results. Any information can be analyzed in the reports, which can be pre-made templates or custom-made by the doctor.

Initially, Thomas' staff met weekly to discuss patients and operations, thus validating data. Staff doctors compare patient recovery rates to evaluate which procedures are most effective. Individual patients are discussed to determine if that patient's management could have been improved.

By reviewing previous procedures, doctors and other staff members are changing the way in which they handle patients. States Thomas,"We actually proved that by analyzing our data, we find there are better ways of doing what we are doing, and we improved."

The database has helped all five hospitals learn from past procedures and as a result, provide better care to patients. Reports Thomas,"We used it as a learning experience and our mortality rate went down."

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