ID: 800 - CLINICAL CASE STUDY Harm event detection: How can we reduce high risk of harm events happening in new zealand primary care? Helmut Modlik1 Patients First   INTRODUCTION HQSC reported in 2017 that 34.7% of NZ hospital patients are harmed by medications, with 29% of that originating in primary care.  The Waitemata DHB’s “Safety in Practice” programme aims to prevent prescribing-related harm by training GPs to better recognise, prevent or manage the risks around such events.  A second, potentially even more effective solution has been developed involving ‘big data’, sophisticated analytics, and real time alerts – the “Conporto EDM” (event detection and mitigation) service. USE OF TECHNOLOGY AND/OR INFORMATION To minimise the risk of treatment harm to patients in primary care, Patients First in partnership with DrInfo, developed and deployed leading edge technology that automatically identifies patients at risk of extreme harm and notifies attending clinicians prior to the patient(s) presenting, to inform their diagnosis and decision-making.  The notification(s) includes evidence of the harm event detected, and if required, access to an integrated summary patient record (incorporating data from all available sources). IMPLEMENTATION/PROCESSES An in-field trial of the Conporto EDM service took place during March 2018 involving 94 general practices and 152 pharmacies at various locations across New Zealand.  The trial targeted the identification and notification of 9 extreme harm events selected by an independent Clinical Governance Group, and operated as follows: GPs received an email notification at the beginning of each day when a patient booked to attend the clinic that day was found to be at risk of an extreme harm event. The notification included a brief description of the harm and a hyperlink to view the patient data supporting the event identification. The GP received the same information in their Patient Management System inbox when the patient presented as part of her/his normal clinical workflow. If further information was required, ‘one-click’ access was provided to a patient summary record ‘Look Up’ that presented an integrated view of all the relevant patient data from all sources – regardless of location. CONCLUSION  Results 100% of Conporto harm event notifications to GPs were successfully sent, opened and reviewed, demonstrating the service operates in a way that fits busy clinical workloads.  All specified harm events were repeatedly detected, and ample quantitative and qualitative evidence generated to show notified clinicians incorporated alerting information into their clinical decision-making, with few false positives evident. Equity issues may have been signalled by the variation in harm incidence and mitigation levels between practices. This will need further careful analysis to confirm. WHAT MAKES YOUR SUBMISSION UNIQUE? Conporto EDM is technically and operationally a world-first.  Real-time querying of large numbers of distributed data sets to pre-emptively identify and notify attending clinicians of extreme harm, with the presentation of supporting evidence and a ‘virtual integrated summary patient record’ to support diagnosis, is without precedent. CORRESPONDENCE Helmut Modlik Patients First helmut.modlik@patientsfirst.org.nz